MAID and Mental illness: Concerns with expanding access

22 November 2018

Research identifies key concerns with expanding access to MAID for those with mental illness as the sole underlying medical condition

Next month, the Council of Canadian Academies (CCA) will report to Parliament on the question of expanding access to medical assistance in dying (MAID) in three major areas: to mature minors, to those with mental illness as the sole underlying medical condition, and by advance directive.
The CCA reports will not make recommendations, but the reports will include available evidence on expanded access to MAID and consider how the evidence informs our understanding of MAID in the Canadian context.
The EFC submitted a brief which outlines academic research and opinion that expressed key concerns about expanding MAID in these ways. Here is an excerpt from the backgrounder to the EFC’s brief, which summarizes some of the reasons not to expand access to MAID for those with mental illness as the sole underlying medical condition. This excerpt is written in the more formal style required of these kinds of briefs, but we thought it was important to share this information as widely as possible. We are always available to answer your questions.

From the brief
The Evangelical Fellowship of Canada (EFC) is the national association of evangelical Christians in Canada. The EFC upholds respect for human life and care of vulnerable persons. Expanding access to euthanasia and assisted suicide (EAS) would place the most vulnerable Canadians at risk and further undermine societal respect for life.

Guidelines and requirements for carrying out EAS can lack clarity, even in cases not involving mental illness, mature minors and advance directives. (For example, in the Netherlands in 2010, 23% of EAS cases were not reported by physicians because they did not consider their actions to fall under the EAS guidelines[2]). The potentially more complicated cases which are the subject of this study involve some of the most vulnerable Canadians, providing a greater potential for abuse, and would be more difficult to govern. 

Mental illness

Canadians affected by mental illness are a vulnerable and stigmatized population.

Persons experiencing mental illness can be particularly vulnerable to suicidal ideation. As one study states about depression, “Indeed hopelessness, closure of the future, and suicidal ideation are key features of the illness.”[3]

Mental illness may impair or annul the ability to give informed consent to death. One study states, “Although psychiatric diagnoses should not be equated with incapacity, some conditions (e.g., psychotic illnesses, neurocognitive disorders, severe depression, anorexia nervosa, and intellectual disability) may increase the risk of incapacity.”[4]

Another study points out that legal decisions on capacity involving depression are sparse, compared to other psychiatric disorders. It goes on to state that the competence assessment tool “MACCAT-T articulation of appreciation has proven difficult to apply with severely depressed patients.”[5] It explains that patients may lose the ability to make decisions about the future because they lose the ability to see the future as “open” or “yet-to-be-determined.” The available futures all manifest themselves as normatively ‘flat.’

An article that noted evidence from clinical ethics and empirical studies indicating that decision-making capacity is often impaired in those with severe depressive illness went on to recommend: “In contrast to other areas where capacity is assumed as a default, ... in these cases it should be assumed to be absent unless assessed thoroughly.”[6]

Capacity can be difficult to assess. A study of psychiatric EAS cases in the Netherlands from 2011 to 2014 indicates there was a disagreement among the consultants in one-quarter (24%) of the requests.[7]  The study goes on to note that EAS proceeded with the disagreements unresolved for most cases.

Research and resources on evaluating capacity are lacking. As commentary in the Canadian Medical Association Journal pointed out, “Discussions, much less evidence-based guidance, of how to evaluate people who request assisted dying because of prolonged grief, autism, schizophrenia, or personality disorders are lacking.”[8] The same article discusses a survey of consultant psychiatrists, most of whom reported that assessing decision-making capacity is a challenging task and that training in making evaluations is suboptimal.

It went on to state: “When the consequence could be premature death, assessments of decision-making capacity need to include rigorous thresholds with carefully articulated justifications. Evidence, however, indicates that this is not necessarily the case.”[9]

The preservation of hope is absolutely paramount. Hope has been described as “a quintessential prerequisite for recovery” in positive psychology.[10] However, extending the option of euthanasia or assisted suicide (EAS) implies there is no hope of recovery for those suffering from mental illness.

One study stated, “While many patients will be disheartened by a series of unsuccessful treatments, it is critical that they are not given a sense that their doctor has ‘given up’.”[11]  

One of the key problems that arises with respect to euthanasia in patients with intolerable suffering due to a psychiatric condition, as Vandenberghe noted, is that: “The process of carefully evaluating a euthanasia request inevitably takes time, in the meantime undermining hope and orientation toward life, both crucial to safeguard the chances for partial recovery.”[12]

Mental illness may not follow a predictable progression. With depression, for example, remission is always a possibility and there is hope as new treatments are developed. As one study stated, “Epidemiologic research has consistently shown that severe mental illness is not always a lifelong or even a chronic condition; substantial numbers of people with severe mental illness have a reduction of both symptoms and associated secondary impairments over time.”[13]

As another study noted, the thesis that “an ‘end-stage’ psychiatric disorder exists and can be reliably diagnosed is clinically unsubstantiated and ethically problematic, and therefore futility judgments are inappropriate.”[14]

Mental illness is experienced by many in Canada, but there is limited treatment available. As CAMH’s factsheet on mental health statistics notes, only half of Canadians experiencing a major depressive disorder receive “potentially adequate treatment.” An estimated 75% of children with mental disorders do not access specialized treatment services. Wait times in Ontario average 6 months to a year. [15]

As a nation, we must not offer death in the absence of treatment. Without a viable alternative, it is arguably not a ‘free’ choice.

From the backgrounder


The EFC opposes all euthanasia and assisted suicide. However, in a context in which these practices are legal, we advocate for stringent safeguards to provide the strongest possible protection for vulnerable Canadians and to minimize the potential for abuse.

This brief summary points to compelling evidence of numerous problems with expanding access to MAID to mature minors, to those with mental illness as the sole underlying factor, and by advance requests. To expand access to MAID in these ways would place some of the most vulnerable Canadians at unacceptable risk.

Our focus as Canadians must be on extending and improving high quality palliative care and treatment for mental illness.

(See the EFC’s submission to the CCA and the full backgrounder to the EFC’s submission.)


[2] Onwuteaka-Philipsen et al., 908, 913. [Onwuteaka-Philipsen, Bregje D, Arianne Brinkman-Stoppelenburg, Corine Penning, Gwen JF de Jong-Krul, Johannes JM van Delden, and Agnes van der Heide. “Trends in End-of-Life Practices before and after the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010: A Repeated Cross-Sectional Survey.” The Lancet 380, no. 9845 (2012): 908–15.]

[3] Broome and de Cates, 587. [Broome, Matthew R., and Angharad de Cates. “Choosing Death in Depression: A Commentary on ‘Treatment-Resistant Major Depressive Disorder and Assisted Dying.’” Journal of Medical Ethics: Journal of the Institute of Medical Ethics 41, no. 8 (August 2015): 586–87.]

[4] Kim and Lemmens, 3. [Kim, Scott, and Trudo Lemmens. “Should Assisted Dying for Psychiatric Disorders Be Legalized in Canada?” Canadian Medical Association Journal, June 21, 2016.]

[5] Owen et al., 178. [Owen, Gareth S., Fabian Freyenhagen, Matthew Hotopf, and Wayne Martin. “Temporal Inabilities and Decision-Making Capacity in Depression.” Phenomenology and the Cognitive Sciences 14, no. 1 (2015): 163–82.]

[6] Broome and de Cates, “Choosing Death in Depression,” 587.

[7] Kim, De Vries, and Peteet, [Kim, Scott Y. H., Raymond G. De Vries, and John R. Peteet. “Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014.” JAMA Psychiatry 73, no. 4 (April 2016): 362–68.]

[8] Kim and Lemmens, “Should Assisted Dying for Psychiatric Disorders Be Legalized in Canada?,” 2.

[9] Ibid., 4.

[10] Park and Chen, 35. [Park, Jinhee, and Roy K. Chen. “Positive Psychology and Hope as Means to Recovery from Mental Illness.” Journal of Applied Rehabilitation Counseling 47, no. 2 (July 1, 2016): 34–42.]

[11] Berk et al., 95. [Berk, Michael, Lesley Berk, Marc Udina, Steven Moylan, Lesley Stafford, Karen Hallam, Sherilyn Goldstone, and Patrick D. McGorry. “Palliative Models of Care for Later Stages of Mental Disorder: Maximizing Recovery, Maintaining Hope, and Building Morale.” The Australian and New Zealand Journal of Psychiatry 46, no. 2 (February 2012): 92–99.]

[12] Vandenberghe, J. “P-647 - Euthanasia in Patients with Intolerable Suffering due to a Psychiatric Condition: Ethical Considerations.” European Psychiatry 27 (2012): 1–1.

[13] Whitley, Palmer, and Gunn, “Recovery from Severe Mental Illness,” 951. [Whitley, Rob, Victoria Palmer, and Jane Gunn. “Recovery from Severe Mental Illness.” Canadian Medical Association Journal 187, no. 13 (April 27, 2015): 951–52.]

[14] Geppert, 36. [Geppert, Cynthia M. A. “Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come.” The American Journal of Bioethics 15, no. 7 (July 3, 2015): 34–43.]