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The Canadian government has delayed a plan to permit medical assistance in dying (MAiD) for patients whose sole qualifying health condition is mental illness.

On January 30, Canada's Health Minister Mark Holland began the parliamentary process needed to halt the change in law that would have allowed MAiD for mental illness. The change had been slated to take effect on March 17. At press time, it was unclear exactly how long the delay would last.

Canada had previously delayed this expansion of the MAiD law by a year from the original expected start date of March 2023. The new delay arises amid disagreements over the change and whether the nation's medical community is equipped to help these patients.

A January 29 report by Parliament's Special Joint Committee on Medical Assistance in Dying concluded that Canada's medical system is not ready for MAiD when mental health is the sole underlying health condition. It cited concerns about the difficulty of accurately predicting the long-term prognosis of a patient with a mental disorder. It also noted concerns about how MAiD would be discussed with vulnerable groups such as Indigenous patients, patients with disabilities, patients living in poverty, and patients in geographically underserved areas.

But the report also included dissenting comments from committee members such as Stan Kutcher , MD, professor emeritus of psychiatry at Dalhousie University, Halifax, Nova Scotia, Canada. Kutcher and fellow dissenters said that the committee had deviated from its mandate, which was to determine whether preparedness criteria had been met. They asserted that the committee's recommendation for delay would reinforce stigma about mental illness.

"The paternalistic view that all competent people with mental disorders are unable to make informed decisions about their medical care is archaic, not aligned with reality, and condescending," they wrote.

'Difficult Balance'

The choice to seek medical assistance in dying is extremely difficult on a personal level and on a national level, said Canadian Prime Minister Justin Trudeau on January 31. "As a society, as a Parliament, we have a responsibility to strike a sometimes difficult balance between respecting the rights, choices, and freedoms of an individual and protecting the most vulnerable," he said. "That is why, for years, we have been conducting studies and evaluations, putting measures in place, proposing debates, and listening to experts. We will continue to be open to all suggestions as we work responsibly."

Since 2016, Canada has allowed clinicians, in certain circumstances, to help patients end their lives. This assistance is permitted when a patient has a grievous and irremediable medical condition and makes a voluntary request for MAiD.

Physicians often assist with death by administering three intravenous medications, including a sedative and a drug that stops the heart, according to the charity Dying With Dignity. The latter group is among the organizations advocating for the expansion of MAiD for people with mental illness as their complaint.

Last year, the Canadian Parliament reconvened the Special Joint Committee on Medical Assistance in Dying to look at whether the nation was ready for the scheduled expansion of the law. The committee received feedback from more than 400 people and organizations. It also heard from 21 witnesses, many of whom supported the expansion of the law.

Among the witnesses was Shelley Birenbaum, chair of the Canadian Bar Association's End of Life Working Group. Birenbaum told Medscape Medical News that the working group was extremely disappointed with the recommendations for delay.

"The suffering of individuals with mental illness is no less real than that of individuals affected by physical illness, and persons with mental illness should have the same agency to determine their healthcare treatment as persons with physical illness if they meet the requirements to do so," she said.

Birenbaum added that a delay in the law's expansion might increase the likelihood of a constitutional challenge. "A blanket prohibition increases suffering and is vulnerable to challenge as violating the equality, security, and liberty guarantees in the Canadian Charter," she said.

Depression May Improve

Critics of MAiD for people whose sole triggering condition is mental illness told the special committee that Canada's approach is too lax. They cited data on MAiD in California, which has a population approximately equal to that of Canada. Since 2016, California has allowed terminally ill adults to obtain and self-administer aid-in-dying drugs.

State data indicate that in 2022, 853 Californians died following their ingestion of the prescribed aid-in-dying drugs. Canada, however, reported 13,241 medically assisted deaths for 2022, according to a government report.

Among the most vocal critics of MAiD for patients with mental illness is John Maher, MD, a psychiatrist and president of the Ontario Association for Assertive Community Treatment and Flexible Assertive Community Teams. He told Medscape Medical News that he welcomed the Canadian officials' delay of MAiD.

In many cases, people's mental health conditions may improve with continued treatment, he said. Moreover, people might be driven to seek MAiD and claim mental illness because of the challenges in their lives, Maher added.

People often seek to end their lives due to despair and loneliness, he continued. "If that's driven by depression, it's obviously treatable" with medication and therapies.

In other cases, people could be offered MAiD for mental health issues that would be better treated with assistance in obtaining shelter and food. Under an expanded MAiD law, patients experiencing despair because of poverty may seek to end their lives because of "the lack of a society welcoming people in any meaningful way," said Maher.

Kerry Dooley Young is a freelance journalist based in Washington, DC.