Insight from the chair of the Expert Panel on MAID and Mental Disorder

News & Updates | August 11, 2023 | Dying With Dignity Canada

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Dr. Mona Gupta is a psychiatrist in Montreal, and she was the chair of the federal Expert Panel on MAID and Mental Disorder. We spoke with Dr. Gupta about her experience on the panel and her insights into MAID for those whose sole underlying condition is a mental disorder. 

Note from DWDC: If your sole underlying medical condition is a mental disorder, you are not eligible to apply for medical assistance in dying (MAID) until March 17, 2027. Learn more

MAID for those whose sole underlying condition is a mental disorder will be legal in March 2024. Can you tell us your position on this change in the law? 

I work with people who have chronic psychiatric and physical disorders and would never want any of them to reach a point in the experience of their illness where they have no other better option but to end their life. As clinicians, we want to do everything we can to relieve the suffering that a person is experiencing. That said, the regime we have in Canada is not an end-of-life regime, it is a system where an eligible person can access an assisted death when they have a grievous and irremediable medical condition. In the context where all other Canadians with chronic disorders can access dying, I don’t see any clinical reason to exclude a group based on their category of disorder. 

Tell us about the mandate of the Expert Panel, the challenges, and the work that was accomplished. 

Overall, the experience of being on the panel was positive. Everyone was sincerely, and in good faith, trying to fulfill the mandate that was given to us which was to make recommendations to the federal government with respect to protocols, safeguards, and guidance for MAID for persons whose sole underlying condition is a mental disorder. 

The mandate of the Expert Panel was not to debate whether people with mental disorders should have access to a medically assisted death, it was to make recommendations about how to structure and organize the practice of assisted dying for people with mental disorders, and how to do that well. The group took seriously the different kinds of concerns that were being raised about MAID for mental disorders; we took a lot of time to consider those arguments and whether our recommendations addressed the concerns. 

Mental and physical disorders are often addressed separately, can you comment on this? 

I think the most important thing the panel contributed to the discussion on assisted dying is to point out that complexity is not something unique to mental disorders. 

There are some very inaccurate ideas out there that physical conditions are straightforward, easy to address, biological, and scientific, and that mental disorders are unpredictable, messy, and complex. The panel’s mandate allowed us to move beyond the very black-and-white portrayal of physical and mental disorders. There can be all kinds of complex cases across the spectrum of medical conditions that clinicians need to be able to address, not just mental disorders, and this allowed the panel to focus on what makes the practice of MAID assessment challenging and what kinds of practices would improve and assist clinicians with the task of doing assessments in the face of different kinds of challenges – regardless of the person’s diagnosis.  

It’s been very surprising to me how difficult it has been to move away from the very simplistic idea that physical conditions are uncomplicated and biological and that mental disorders are complex and socially determined. It’s as though if you have a physical condition, you can’t also be poor or unhoused but if you have a mental disorder, it is always the case or it’s somehow different than having a physical disorder and being in that kind of situation. This perpetuates the stigma associated with mental disorders and does a disservice to those who live with them. The fact that there was an entire panel focused on this one group of people says a lot about society’s desire to treat this group as entirely different when, in fact, clinically there is no reason to do that. It seems that the idea of MAID for mental disorders has superseded the reality of the range of complex cases in clinical practice.  

Ultimately, the panel recommendations suggested that the current criteria and safeguards were sufficient and robust enough for assessments where the sole underlying condition is a mental disorder. Can you explain this reasoning? 

MAID criteria and safeguards exist in the Criminal Code of Canada, but nobody practices medicine – or does MAID assessments – based just on that. The Criminal Code offers a broad framework, like the frame of a portrait, but all of the details in the portrait need to be fleshed out by the different actors who regulate and work in health care. The Criminal Code is no more specific for someone with a physical disorder than a mental disorder. You simply cannot introduce all of the details that clinicians need in order to practice into that framework. It doesn’t belong there. We rely on different kinds of clinical guidance and recommendations including the clinical practice guidelines for the various conditions that we are treating.  

The kinds of treatments that are appropriate for a patient’s condition are the same whether it is in the context of a MAID assessment or not. If I am presented with a patient with a mental disorder, I will refer to the practice guidelines for that condition and I am going to draw on all the usual resources and guidance to establish a treatment plan with that person. It’s important to remember that people who are doing MAID practice are trained clinicians, they have clinical practices in other areas aside from MAID, and all of the usual rules and guidance that apply to clinical practice apply to MAID as well. 

The panel published its recommendations on May 13, 2022; it recommended the development of the Model Practice Standard for nurse practitioners and physicians for the assessment of MAID requests in situations that raise questions about incurability, irreversibility, capacity, suicidality, and the impact of structural vulnerabilities. Do you think the standards of practice that were developed and published in March 2023 address these questions for MAID assessors?  

A regulatory practice standard is one form of guidance that supports clinical practice. It tells clinicians what the expectations and requirements are from the regulator whose job it is to ensure clinicians practice in the public interest. The Model Practice Standard may be useful to physicians and nurse regulators who want to update their existing MAID practice standards to take into account some of the challenges of Track 2 cases including mental disorders as a sole underlying condition and, in so doing, provide further guidance to their members – nurse practitioners and physicians involved in MAID practice. That said, regulatory standards are not intended to describe every detail of good practice. Some of that also comes from the guidelines that clinicians set for themselves often through the work of professional associations or clinical consortia. So, I think the Model Practice Standard – if it is adopted by physicians and nurse regulators – gives guidance as to the requirements of practitioners involved in MAID practice. But the clinical community will have to continue working together to develop best practices in this area. 

What did the panel learn from the international experience of assisted dying for people with mental disorders? 

There are very few jurisdictions in the world that allow MAID for mental disorders, but those that do, do not have separate legal safeguards or different eligibility criteria.  

We were able to speak to colleagues from these countries for insight into their practices and challenges and that was very helpful to the panel. The Dutch Psychiatric Association has developed very substantive practice guidelines that have been updated several times since the early 2000s. They offer a lot of detail to clinicians on how they can best serve their patients. Do they cover every scenario that could possibly exist? No. Have they resolved all possible controversies? Of course not. But it was a useful tool for our group to have access to. 

Any last words? 

We need to move away from the idea that people with mental disorders cannot make decisions about their own lives by virtue of having a mental disorder. I get that some cases might be difficult, but we can say that about physical conditions as well. If we are concerned that some people with mental disorders might not have had access to certain resources and that is part of the reason they are asking for MAID, then, let’s focus on getting the patient the help they need rather than excluding them from access to MAID as though it is a solution to that problem. It might seem easier to simply exclude people with mental disorders from being able to access MAID, but we need to remember that there are people at the end of that exclusion, and exclusion as a policy choice sends the message that they are not entitled to make choices about their own lives the way everyone else is.  

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