AMAD Committee Report

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Appendix B: Summary of Recommendations on Mental illness as a Sole Underlying Medical Condition for Eligibility for Maid Prior to the Expert Panel Report

Below is a table of the recommendations and conclusions of various panels and groups regarding MD-SUMC from 2015 to 2021. It does not include the Expert Panel recommendations found in Annex A.

Table 1—Recommendations and Conclusions Concerning the Legalization of Medical Assistance in Dying where Mental Illness is the Sole Underlying Medical Condition

Report	Recommendation
External Panel on Options for a Legislative Response to Carter v. Canada, “Consultations on Physician-Assisted Dying: Summary of Results and Key Findings,” Final Report, 15 December 2015 * No recommendations made.	“The Panel heard widely diverging views on where mental illness might fit – or not fit – in a framework for physician-assisted death in Canada. At one end of the spectrum, Professor Eike-Henner Kluge [an expert in biomedical ethics from the University of Victoria] argued that, based on the principles of equality, even if a person’s mental illness rendered them legally incompetent, that incompetence should not disentitle individuals who otherwise meet the Carter eligibility criteria from accessing physician-assisted dying. On the other hand, groups such as the Catholic Health Alliance of Canada argued that mental illnesses should not be included in the scope of the medical condition eligibility criterion.” [p. 60]
Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying, Final Report, 30 November 2015	Recommendation 18 “‘Grievous and irremediable medical condition’ should be defined as a very severe or serious illness, disease or disability that cannot be alleviated by any means acceptable to the patient. Specific medical conditions that qualify as ‘grievous and irremediable’ should not be delineated in legislation or regulation.” [p. 7]
Parliament of Canada, Special Joint Committee on Physician‑Assisted Dying, Medical Assistance in Dying: A Patient‑Centred Approach, First report, February 2016	Recommendation 3 “That individuals not be excluded from eligibility for medical assistance in dying based on the fact that they have a psychiatric condition.” [p. 15]
Canadian Council of Academies, State of Knowledge on Medical Assistance in Dying for Mature Minors, Advance Requests, and Where a Mental Disorder Is the Sole Underlying Medical Condition, Summary of reports [The State of Knowledge on Medical Assistance in Dying for Mature Minors, The State of Knowledge on Advance Requests for Medical Assistance in Dying, and The State of Knowledge on Medical Assistance in Dying Where a Mental Disorder is the Sole Underlying Medical Condition], 2018 * No recommendations made.	“Given this wide range of perspectives and the controversial nature of the topic, Working Group members do not agree on some fundamental issues [regarding mental illness as a sole underlying condition for eligibility for MAID]. … In some areas, the Working Group did not reach consensus on the interpretation and/or significance of the evidence, or about what constitutes relevant evidence.” [p. 27]
Quebec, Ministère de la Santé et des Services sociaux, Groupe d’experts sur la question de l’inaptitude et l’aide médicale à mourir, L’aide médicale à mourir pour les personnes en situation d’inaptitude: le juste équilibre entre le droit à l’autodétermination, la compassion et la prudence [Quebec, Ministry of Health and Social Services, Expert Group on the Question of Capacity and Medical Assistance in Dying, Medical assistance in dying for persons who are incapable: balancing the right to self‑determination, compassion and prudence], 2019 [available in French only]	Recommendation 12 “That the equal human rights of persons with an intellectual disability or mental health disorder be upheld.” [translation] [p. 130]
Government of Canada, What We Heard Report: A Public Consultation on Medical Assistance in Dying (MAID), Consultations report, March 2020. * No recommendations made.	“Most of the comments were not in favour of expanding MAID to people who suffer from mental illness. They had concerns that people who had an illness such as depression may feel that MAID is their only option. But there may be effective treatments that could help them to feel better. … But others felt that people with mental illness should be eligible for MAID in certain situations. This would include where the mental illness is really affecting the person and where treatment does not work. Some noted that mental health conditions can cause as much suffering and pain as physical conditions. Mental health conditions may not respond to treatment. Sometimes this can make people attempt suicide in dangerous ways rather than ending their life in a safe way.” [p. 3]
The Halifax Group, Faces of Aging – MAiD Legislation at a Crossroads: Persons with Mental Disorders as Their Sole Underlying Condition, IRPP [Institute for Research on Public Policy], 30 January 2020	Recommendation 1 “The federal and Quebec governments should not amend their laws to exclude all persons with MD‑SUMC [mental illness is the sole underlying condition] from accessing MAiD.” * For other related recommendations, see the report.
Expert Advisory Group on Medical Assistance in Dying, Canada at a Crossroads: Recommendations on Medical Assistance in Dying and Persons with a Mental Disorder, Evidence‑based critique of the Halifax Group IRPP report, 13 February 2020 Note: This is a response to the IRPP report by a group of mental health experts and individuals with lived experience of mental illness.	Core recommendation “MAID policy and legislation should explicitly acknowledge that determinations of irremediability and irreversible decline cannot be made for mental illnesses at this time, and therefore applications for MAID for the sole underlying medical condition of a mental disorder cannot fulfill MAID eligibility requirements.” [p. 14] * For ancillary recommendations, see the report.
Association des médecins psychiatres du Québec [Association of Psychiatrists of Quebec], Access to medical assistance in dying for people with mental disorders, Discussion paper, November 2020	“[W]e think that it is a person’s clinical circumstances and not his diagnosis that should determine MAID eligibility. Patients whose sole underlying medical condition is a mental disorder or mental illness should not be systematically excluded from accessing MAID.” [p. 14] * While the paper focuses on this issue, the way it is structured does not allow for extractions of short quotes. See the report for further details.
Quebec, National Assembly, Select Committee on the Evolution of the Act respecting end-of-life care, Report of the Select Committee on the Evolution of the Act respecting end-of-life care, December 2021. * Scroll to the bottom of the webpage for the link to the report	Recommendation 11 “The Committee recommends that access to medical aid in dying not be extended to persons whose only medical condition is a mental disorder; that, to this end, section 26 of the Act respecting end-of-life care be amended.” [p. 64]

Report

Recommendation

External Panel on Options for a Legislative Response to Carter v. Canada, “Consultations on Physician-Assisted Dying: Summary of Results and Key Findings,” Final Report, 15 December 2015

* No recommendations made.

“The Panel heard widely diverging views on where mental illness might fit – or not fit – in a framework for physician-assisted death in Canada. At one end of the spectrum, Professor Eike-Henner Kluge [an expert in biomedical ethics from the University of Victoria] argued that, based on the principles of equality, even if a person’s mental illness rendered them legally incompetent, that incompetence should not disentitle individuals who otherwise meet the Carter eligibility criteria from accessing physician-assisted dying. On the other hand, groups such as the Catholic Health Alliance of Canada argued that mental illnesses should not be included in the scope of the medical condition eligibility criterion.” [p. 60]

Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying, Final Report, 30 November 2015

Recommendation 18

“‘Grievous and irremediable medical condition’ should be defined as a very severe or serious illness, disease or disability that cannot be alleviated by any means acceptable to the patient. Specific medical conditions that qualify as ‘grievous and irremediable’ should not be delineated in legislation or regulation.” [p. 7]

Parliament of Canada, Special Joint Committee on Physician‑Assisted Dying, Medical Assistance in Dying: A Patient‑Centred Approach, First report, February 2016

Recommendation 3

“That individuals not be excluded from eligibility for medical assistance in dying based on the fact that they have a psychiatric condition.” [p. 15]

Canadian Council of Academies, State of Knowledge on Medical Assistance in Dying for Mature Minors, Advance Requests, and Where a Mental Disorder Is the Sole Underlying Medical Condition, Summary of reports [The State of Knowledge on Medical Assistance in Dying for Mature Minors, The State of Knowledge on Advance Requests for Medical Assistance in Dying, and The State of Knowledge on Medical Assistance in Dying Where a Mental Disorder is the Sole Underlying Medical Condition], 2018

* No recommendations made.

“Given this wide range of perspectives and the controversial nature of the topic, Working Group members do not agree on some fundamental issues [regarding mental illness as a sole underlying condition for eligibility for MAID]. … In some areas, the Working Group did not reach consensus on the interpretation and/or significance of the evidence, or about what constitutes relevant evidence.” [p. 27]

Quebec, Ministère de la Santé et des Services sociaux, Groupe d’experts sur la question de l’inaptitude et l’aide médicale à mourir, L’aide médicale à mourir pour les personnes en situation d’inaptitude: le juste équilibre entre le droit à l’autodétermination, la compassion et la prudence [Quebec, Ministry of Health and Social Services, Expert Group on the Question of Capacity and Medical Assistance in Dying, Medical assistance in dying for persons who are incapable: balancing the right to self‑determination, compassion and prudence], 2019 [available in French only]

Recommendation 12

“That the equal human rights of persons with an intellectual disability or mental health disorder be upheld.” [translation] [p. 130]

Government of Canada, What We Heard Report: A Public Consultation on Medical Assistance in Dying (MAID), Consultations report, March 2020.

* No recommendations made.

“Most of the comments were not in favour of expanding MAID to people who suffer from mental illness. They had concerns that people who had an illness such as depression may feel that MAID is their only option. But there may be effective treatments that could help them to feel better.

…

But others felt that people with mental illness should be eligible for MAID in certain situations. This would include where the mental illness is really affecting the person and where treatment does not work. Some noted that mental health conditions can cause as much suffering and pain as physical conditions. Mental health conditions may not respond to treatment. Sometimes this can make people attempt suicide in dangerous ways rather than ending their life in a safe way.” [p. 3]

The Halifax Group, Faces of Aging – MAiD Legislation at a Crossroads: Persons with Mental Disorders as Their Sole Underlying Condition, IRPP [Institute for Research on Public Policy], 30 January 2020

Recommendation 1

“The federal and Quebec governments should not amend their laws to exclude all persons with MD‑SUMC [mental illness is the sole underlying condition] from accessing MAiD.”

* For other related recommendations, see the report.

Expert Advisory Group on Medical Assistance in Dying, Canada at a Crossroads: Recommendations on Medical Assistance in Dying and Persons with a Mental Disorder, Evidence‑based critique of the Halifax Group IRPP report, 13 February 2020

Note: This is a response to the IRPP report by a group of mental health experts and individuals with lived experience of mental illness.

Core recommendation

“MAID policy and legislation should explicitly acknowledge that determinations of irremediability and irreversible decline cannot be made for mental illnesses at this time, and therefore applications for MAID for the sole underlying medical condition of a mental disorder cannot fulfill MAID eligibility requirements.” [p. 14]

* For ancillary recommendations, see the report.

Association des médecins psychiatres du Québec [Association of Psychiatrists of Quebec], Access to medical assistance in dying for people with mental disorders, Discussion paper, November 2020

“[W]e think that it is a person’s clinical circumstances and not his diagnosis that should determine MAID eligibility. Patients whose sole underlying medical condition is a mental disorder or mental illness should not be systematically excluded from accessing MAID.” [p. 14]

* While the paper focuses on this issue, the way it is structured does not allow for extractions of short quotes. See the report for further details.

Quebec, National Assembly, Select Committee on the Evolution of the Act respecting end-of-life care, Report of the Select Committee on the Evolution of the Act respecting end-of-life care, December 2021.

* Scroll to the bottom of the webpage for the link to the report

Recommendation 11

“The Committee recommends that access to medical aid in dying not be extended to persons whose only medical condition is a mental disorder; that, to this end, section 26 of the Act respecting end-of-life care be amended.” [p. 64]