Mental illness and the moral boundaries of MAiD

The federal government is presently considering whether to expand medical assistance in dying (MAiD). When introduced in 2016, MAiD was limited to patients with grievous and irremediable medical conditions whose deaths were “reasonably foreseeable.” In 2021, the law was amended to remove the requirement that a patient’s death be foreseeable in order for them to apply for MAiD. The new legislation created two “tracks” for physician-assisted death: Track 1 for those with intolerable, terminal medical conditions, and Track 2 for patients with severe, incurable conditions which are not terminal. Currently, MAiD is only available for those with physical disabilities and medical conditions. Under the 2021 law, MAiD was to be extended to those suffering solely from mental illness by 2023. This planned expansion proved to be controversial and has been twice delayed, first until 2024, and then to 2027.

The expansion of MAiD has been criticized by mental health professionals, disability advocates, and those concerned about how poverty and the lack of access to adequate care can shape patients’ decisions. Yet to assess these criticisms and what any future expansion of MAiD should look like, it is crucial to keep in mind the justifications for permitting physician-assisted death in the first place.

There are two basic ethical justifications for MAiD, one based on autonomy and one based on well-being. The ethical arguments for MAiD carve out an exception to the prohibition on intentionally ending another person’s life by claiming that, under certain circumstances, assisting an individual to die prematurely is the right thing to do.

Autonomy-based justifications for MAiD are rooted in the value of a patient’s ability to determine the course of their life, including how their ultimate death is managed. A severe medical condition can prevent patients from exercising any self-determination over end-of-life scenarios. For instance, the two women whose legal battles directly inspired the creation and legalization of MAiD, Sue Rodriguez and Gloria Taylor, suffered from amyotrophic lateral sclerosis (ALS), which progressively diminishes physical and neurological functions over time. In situations like these, MAiD can enhance a patients’ autonomy by enabling them to make decisions about end-of-life care before their capacity to do so is diminished or eliminated altogether. However, autonomy-based considerations can only justify MAiD in situations where the patient’s condition is degenerative. This accounts for many Track 1 applicants for MAiD in Canada, but not Track 2. In 2024, the vast majority of people who received MAiD were classified as Track 1, accounting for 95.6 percent of all MAiD cases, with terminal cancer being the most common condition.

Well-being-based justifications for MAiD begin from the premise that suffering is intrinsically bad and should be avoided or alleviated where possible. Living is valuable because it makes possible the experience and pursuit of all other goods. Without being alive, you cannot pursue your goals, experience happiness, or do anything at all. Yet it is possible for a person’s health to be so compromised that they can no longer pursue their goals or experience happiness anyway. If the only life available to someone is one of intolerable suffering, helping them to die might be a mercy. In short, well-being arguments contend that intolerable suffering can override whatever value one’s life would otherwise have and thereby justify medically-assisted death. The Supreme Court had these kinds of considerations in mind when it ruled that a total prohibition on physician-assisted dying violated Section 7 of the Charter.

A mental illness is rarely fatal on its own. As a result, there will be few cases in which someone seeks MAiD for mental illness where impending death is a relevant consideration. In such cases, the justification for MAiD would rest primarily on claims of intolerable suffering. However, determining whether a person’s mental anguish is truly intolerable or untreatable can be challenging. In the realm of mental health, clinicians rely heavily on patients’ self-reported experiences, which makes it difficult to establish whether their suffering is in fact intolerable or incurable.

Even when patients are not deliberately overstating their suffering, they may simply be mistaken about whether it is treatable. For someone experiencing severe depression or suicidal ideation, the suffering can feel intolerable in the moment. Yet many patients later discover that their condition can be managed with therapy, medication, or other interventions. This epistemic difficulty is compounded by the fact that it remains unclear whether Canadian law would require an applicant seeking MAiD on the basis of mental illness to obtain approval from a psychiatrist or psychologist rather than a general physician. It is difficult enough for trained mental health specialists to determine whether a condition is truly intolerable or incurable, let alone for a physician without expertise in mental health.

A further problem is that public health care in Canada rarely extends to mental health services, and therapy or medications are usually prohibitively expensive for those lacking work-related benefits. A person suffering from a treatable mental health condition could plausibly qualify for MAiD just because they cannot afford to access adequate care. Disability advocates have observed that the inability to access resources has led some disabled people to choose MAiD. A 66-year-old quadriplegic man in Québec sought out MAiD after the lack of a therapeutic mattress during a hospital stay left him injured and in extreme pain. Denying patients adequate care and then offering them death instead is an ethically indefensible abdication of the duty to care.

Relatedly, mental health conditions are often aggravated by social and economic problems that can be solved by government action. In one widely-reported case, a homeless St. Catherine’s man applied for MAiD because he could not find housing. He later withdrew his application after a GoFundMe campaign raised enough money for him to secure an apartment. Elsewhere, a Toronto woman who had a chemical sensory disorder sought MAiD when she could not find housing that met her needs. While the government declined to help her find adequate shelter, it had no problem facilitating her death. Critics of MAiD worry that the government is coming to see MAiD as a cost-saving measure which is cheaper to provide than palliative care, social assistance, or the funding needed to support a robust public health care system.

If mental illness is added as grounds for MAiD, we should expect that some people will apply on the basis of psychological suffering rooted in poverty, homelessness, or even profound loneliness. These sources of distress are often addressable, but their remedies are social or economic rather than strictly medical. Because they are, in principle, remediable, governments cannot ethically justify providing MAiD where the suffering is neither truly intolerable nor incurable. Solutions exist, and cost alone cannot justify prioritizing the ending of lives over confronting the social conditions that produce such distress.

MAiD affirms individual agency and choice and can—and should—be part of a robust health care system. But its expansion must be accompanied by substantial safeguards. There are many circumstances in which assisting someone in ending their life may be ethically justified if their suffering is truly intolerable. Still, it is naïve to imagine that the decision to pursue MAiD is made in a vacuum, insulated from social, economic, and personal pressures. A choice cannot be considered fully autonomous when all better alternatives have been foreclosed. Expanding MAiD to include mental illness would be unconscionable without first meaningfully improving access to mental health care across Canada.

Eric Wilkinson is a postdoctoral fellow in the Department of Philosophy at the University of British Columbia.