TO:        Special Joint Committee on Medical Assistance in Dying

FROM: Rebecca Vachon, PhD., Health Program Director

     Andreae Sennyah, Director of Policy

DATE:   November 16, 2023

SUBJECT: Readiness for Expanding MAID where Mental Disorder is the Sole Underlying Medical Condition (MD-SUMC)

RECOMMENDATION
Cardus is a non-partisan think tank. We recommend an indefinite pause for MD-SUMC and assert that Canada is not and will not be prepared for the 2024 expansion. The committee must consider readiness beyond that of practitioners, including readiness of the existing MAID system, the most affected populations, and the Canadian public.

CONSIDERATIONS TO ASSESS READINESS

1. Readiness of the existing MAID system: Inherent problems with reporting and oversight and the much higher than anticipated provision of MAID under current criteria warrant further study before expanding eligibility.

• The federal monitoring system is based on self-reported data from MAID assessors and providers, without independent review to ensure compliance.
  • Provinces provide limited data on MAID; only Ontario and Quebec have publicly available reports. 1 1 Jaro Kotalik, “Monitoring of MAID: Deficits of Transparency and Accountability,” in Medical Assistance in Dying (MAID) in Canada: Key Multidisciplinary Perspectives, 124. https://link.springer.com/book/10.1007/978-3-031-30002-8 Quebec’s reports 2 2 Commission sur les Soins de Fin de Vie. 2020. Rapport Annuel d’Activités. Gouvernement du Québec: Québec https://csfv.gouv.qc.ca/en/publications; Commission sur les Soins de Fin de Vie. 2022. Rapport Annuel d’Activités Gouvernement du Québec: Québec. https://csfv.gouv.qc.ca/en/publications. note cases with compliance issues and missingdata, but provide no details about investigations or enforcement.
• Ambiguous eligibility criteria results in varied interpretations amongst MAID assessors. The system is, thus, vulnerable to patients “shopping” for assessors and providers until their request is approved. 3 3 Sephora Tang, K. Sonu Gaind, and Timothy Lau, “MAID for Persons with Mental Illness as a Sole Eligibility Criterion,” in Medical Assistance in Dying (MAID) in Canada: Key Multidisciplinary Perspectives, 278. https://link.springer.com/book/10.1007/978-3-031-30002-8
• Claims that very few MD-SUMC patients with long histories of treatments would qualify for MAID fail to consider that legislation does not require the exhaustion of treatment options.
• Projections have consistently underestimated the number of MAID deaths. Health Canada previously projected that MAID deaths would reach a “steady state of 2.05%” of total deaths annually. 4 4 4 Government of Canada, “Canada Gazette, Part 2, Volume 152, Number 16.”https://www.gazette.gc.ca/rp-pr/p2/2018/2018-08-08/html/sor-dors166-eng.html. Last year, they projected deaths would reach 4% in 2033. 5 5 Government of Canada, “Canada Gazette, Part 1, Volume 156, Number 21.” https://www.gazette.gc.ca/rp-pr/p1/2022/2022-05-21/html/reg1-eng.html. Yet Canada has already surpassed this projection with actual MAID deaths comprising 4.1% of total deaths in 2022, a decade earlier than anticipated. 6 6 Health Canada, “Fourth Annual Report on Medical Assistance in Dying in Canada 2022,” (Ottawa, October 2023).https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-medical-assistance-dying-2022.html.
  • Compared to California, where assisted death remained at 0.15% of all deaths from 2020 to 2021, Canada’s year-over-year increase of more than 30% is striking. A total of 3,344 Californians received assisted death from 2016 to 2021, contrasted with 31,664 Canadians in the same period. 7 7 Daryl Pullman, “Slowing the Slide Down the Slippery Slope of Medical Assistance in Dying: Mutual Learnings for
    Canada and the US,” The American Journal of Bioethics 23, no. 11 (2023): 64-72

2. Readiness of the most affected populations: Expanding MAID for MD-SUMC is irresponsible given the significant barriers and gaps in mental health care provision. Further study of the impact that expansion could have on suicide prevention, suicide contagion, and Indigenous populations is needed.

• September 2023 polling found that among those who sought mental health care in the past year, 41% experienced barriers to access; this impacted women and younger Canadians more heavily. 8 8 Angus Reid Institute, “Mental Health and MAID: Canadians Who Struggle to Get Help More Likely to Support Expanding Eligibility,” September 28, 2023. https://angusreid.org/mental-health-care-access-maid-mental-illness/.
  • Statistics Canada reported that in 2022 more than 1 in 3 Canadians who have a mood, anxiety or substance use disorder said their health and mental health care needs were partially or fully unmet. 9 9 9 Stephenson, E., 2023, “Mental disorders and access to mental health care,” Insights on Canadian Society, Statistics
    Canada Catalogue no. 75-006-X.https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2023053-eng.htm.
• Experts indicate expansion could undermine suicide prevention 10 10 Canadian Association for Suicide Prevention, “CASP Issues Statement About MAiD for Mental Illness”, Dec 14,
  2022 https://suicideprevention.ca/media/statement-on-the-expansion-of-medical-assistance-in-dying-to-those-without-a-reasonably-foreseeable-death/.; Mara Grunau, Robert Olson, and Crystal Walker, “Medical Assistance in Dying (MAID) and Suicide: A Community Perspective,” in Medical Assistance in Dying (MAID) in Canada: Key Multidisciplinary Perspectives, 245-252. https://www.camh.ca/-/media/files/pdfs---public-policy-submissions/camh-submission-to-special-committee-on-maid-final-pdf.pdf. and emphasize the inherent ambiguity between a reasoned request for MD-SUMC and suicidality. 11 11 Centre for Addiction and Mental Health, Brief to the Special Joint Committee on Medical Assistance in Dying, May 6, 2022; Tang, Gaind, and Lau, “MAID for Persons with Mental Illness”, 272-276.https://www.camh.ca/-/media/files/pdfs---public-policy-submissions/camh-submission-to-special-committee-on-maid-final-pdf.pdf.
• Recent studies found that the introduction of assisted death is not associated with lower (non-assisted) suicide rates 12 12 Anne M. Doherty, Caitlyn J. Axe, and David A. Jones, “Investigating the Relationship between Euthanasia and/or Assisted Suicide and Rates of Non-Assisted Suicide: Systematic Review,” BJPsych Open 8, no. 4 (July 2022): e108. and may even be associated with higher suicide rates 13 13 David Albert Jones, “Euthanasia, Assisted Suicide, and Suicide Rates in Europe,” Journal of Ethics in Mental Health 11 (2022): 1–35. . Further study is needed to determine if MAID could act as a suicide contagion.
• The federal government is currently consulting with Indigenous communities about MAID, recognizing inequities they face. This expansion cannot be implemented until that engagement – which only began in August 2023 with reporting planned for 2025 14 14 Health Canada, “Engagement on Indigenous Perspectives on Medical Assistance in Dying.”https://www.canada.ca/en/health-canada/programs/engagement-indigenous-perspectives-medical-assistance-dying.html#a1. – is complete and there is time to meaningfully consider the results.

3. Readiness of the Canadian public: A majority of Canadians do not support expanding MAID for MD-SUMC.

• September 2023 polling found that only 28% of Canadians support the expansion.
  • 82% of Canadians believe mental health care should be improved first before MAID is expanded to mental illness. 15 15 Angus Reid Institute, “Mental Health and MAID”.
• In June 2023, Quebec’s Bill 11 excluded mental disorders as a sole underlying condition from eligibility.