Canada is making medical assistance in dying (MAID) accessible to people with mental illness as a sole condition next year, and recent commentary has raised the question of where drug addiction falls under this umbrella.
A prominent addictions expert recently said MAID should be available to drug addicts, sparking debate over whether this could or should be the case.
“It’s not fair to exclude people from eligibility purely because their mental disorder might either partly or in full be a substance-use disorder,” Dr. David Martell of Nova Scotia Health said at the Canadian Society of Addiction Medicine (CSAM) conference in Victoria, British Columbia, held Oct. 19–21.
He presented a framework for assessing MAID for drug addicts, which had the consensus of a group of “mental health leaders, including addiction medicine providers” in Nova Scotia, he said in his abstract.
That consensus suggests offering MAID to drug addicts is an idea that has some support in the medical community—the community that is determining in many ways how MAID is administered.
Dr. Martell’s presentation drew criticism from some politicians and people who work with drug addicts after his comments were widely publicized by Vice magazine and the National Post.
In Parliament last week, Conservative shadow minister for health Dr. Stephen Ellis blamed the Liberal government for contributing to addiction by distributing “safe supply” drugs, then offering MAID to addicts.
“The Liberal government is giving away opioids for free. And then ... when you’re addicted to these opioids ... they’re going to kill you,” he said.
Health Canada told The Epoch Times it is not planning to expand MAID eligibility solely on the criteria of drug addiction. However, the question remains to what extent addicts may fall under the “mental illness” eligibility criteria.
Liberal Health Minister Mark Holland said in an annual MAID report released Oct. 18 that Ottawa will work with the provinces to ensure vulnerable people will be protected.
“Through this ongoing collaboration, we continue to advance core principles of safety, accessibility and the protection of persons who may be vulnerable, throughout the MAID system,” Mr. Holland said.
‘Incurable’
When asked how drug addiction specifically will influence eligibility assessments, Health Canada responded that each patient must meet all three of the following criteria: He or she must have a “serious and incurable” condition, be in an “advanced state of irreversible decline,” and experience “enduring and intolerable suffering.”The word “incurable” in that first criterion is key. Current legislation says a person’s condition must be “irremediable,” and many experts have expressed concern about labelling mental illnesses irremediable.
“These illnesses are not curable per se, but they are possible to treat and manage (e.g. with medications, rehabilitation, other lifestyle changes, etc.),” the Centre for Addiction and Mental Health (CAMH) noted in a 2017 policy paper. “Every day vast numbers of Canadians find ways to live well with chronic and recurrent illnesses.”
Karandeep Sonu Gaind, an associate professor of psychiatry at the University of Toronto, also raised the question of irremediability regarding mental illness in an article for The Conversation.
“The blunt and indisputable reality is that, unlike for much more predictable medical conditions with better understood biologies, it remains currently impossible to predict whether mental illness is irremediable,” Dr. Sonu Gaind said.
Health Canada said doctors can determine “incurability” by looking at all past treatment attempts. The doctors must conclude that “there are no reasonable treatments remaining.”
While Health Canada said “stringent eligibility criteria and robust procedural safeguards” are in place, such criteria and safeguards have repeatedly been called into question since Canada first legalized MAID in 2016.
Criteria and Safeguards
MAID was initially available only to those whose death was “reasonably foreseeable.” Then in 2021, it was opened up to people with “grievous and irremediable” illnesses and disabilities, even if those conditions were not terminal. Mental illnesses were not yet included.Having two independent doctor assessments became a requirement, along with other conditions, such as the patient being at least 18 years old and mentally competent to consent to MAID.
But mental illness did not necessarily exclude a patient from eligibility. “If you have a mental illness along with other medical conditions, you may be eligible for medical assistance in dying,” the government’s guidance says.
Last year, The Epoch Times spoke with Sharon Danley, whose son suffered from birth defects and also mental illness. Given that her son, 46, was mentally ill and suffered from suicidal ideation, Ms. Danley disagreed with doctors’ assessments that he was eligible for MAID. He nonetheless received MAID on Dec. 12, 2021.
MAID eligibility will be opened to people with mental illness as a sole condition on March 17, 2024. The health-care community has been debating what the precise criteria should be for approving MAID based on mental illness.
CAMH said in a March 14 press release that it was working to establish framework and decision-making supports for clinicians.
“As others across the country undertake similar work, the [CAMH] working group is offering its considerations on the key issues related to defining a ‘grievous and irremediable’ mental illness and distinguishing a request for MAiD from suicidality,” the release said.
Individual doctors will have to judge on a case-by-case basis whether patients meet the criteria.
Dr. Martell, whose comments about offering MAID to drug addicts sparked the current debate, acknowledged these considerations in the framework he presented at the CSAM conference.
“Crucial to this process is having a process to determine whether a mental health disorder is truly irremediable, knowing the difference between a person being suicidal and having a reasoned wish to die, and understanding what influence vulnerability has on the request,” the framework abstract says.
While Dr. Martell has expressed support for offering MAID to people with substance-use disorder, other doctors have similarly made headlines with suggestions regarding MAID eligibility.
Dr. Louis Roy of the Quebec College of Physicians told a parliamentary joint committee on MAID on Oct. 7, 2022, that “emancipated minors between the ages of 14 and 17” should be considered for MAID eligibility. He also said babies could be considered if they have “severe deformities and very serious syndromes for which the chances of survival are virtually nil.”
“[The deformities] will cause so much pain that a decision must be made to not allow the child to suffer,” he said.
Slippery Slope
Accessibility to MAID has been broadened step by step since 2016, and the numbers of Canadians receiving it have grown rapidly—Health Canada data released on Oct. 18 says MAID deaths rose about 31 percent from 2021 to 2022. About 4 percent of all deaths in Canada during that period were due to MAID.The term “slippery slope” has been often used in discussions around MAID, including in a letter to the Canadian Medical Association Journal written by Dr. John Wootton of Shawville, Quebec, in 2017.
“We are likely to become more and more comfortable with it, and more and more permissive as times goes by. As slippery slopes go, this is one where the coefficient of friction also approaches zero,” he wrote.
Katharina Stevens, an assistant professor of philosophy at the University of Lethbridge, has done a lot of thinking about slippery slopes, having studied the logic of how one decision may lead to certain future consequences.
“If you make one decision, there will be something about that decision that will make you make another decision, and so on. It’s like a domino effect,” she told The Epoch Times, explaining the slippery slope concept. “It'll cause you to make a really bad [decision] ... at some point in the end.”
She cited UCLA law professor Eugene Volokh’s ideas on how a piece of legislation may go down a slippery slope. If legislation changes public attitude or creates certain cost benefits, for example, it may lead to future, undesirable consequences.
While Ms. Stevens said she’s not of the opinion that MAID will go down a steep slippery slope, she gave hypothetical, illustrative examples of how one might apply Mr. Volokh’s ideas to MAID in Canada.
It may be that “people become desensitized to euthanasia and therefore at some point, willy nilly, you can ... feel a little bit bad on a Sunday evening [and receive MAID],” she said, tongue-in-cheek. Or it may cause people to think it’s “cheaper to kill people with drug addictions rather than treat them.”
Some say this is where MAID is headed—that people will opt for MAID when they can’t get the services that might ease their suffering.
Access to mental health care and quality palliative care is a problem in Canada, said Rebecca Vachon, health program director for think tank Cardus, in an Oct. 25. release.
“The health minister needs to prioritize helping suffering Canadians live better rather than simply providing the means for a premature death,” she said.
