The State of Knowledge On Medical Assistance in Dying Where A Mental Disorder Is The Sole Underlying Medical Condition

The State of Knowledge on Medical Assistance
in Dying Where a Mental Disorder Is the Sole

Underlying Medical Condition
The Expert Panel Working Group on MAID
Where a Mental Disorder Is the Sole
Underlying Medical Condition
ASSESSING EVIDENCE. INFORMING DECISIONS.

THE STATE OF KNOWLEDGE ON MEDICAL ASSISTANCE
IN DYING WHERE A MENTAL DISORDER IS THE SOLE
UNDERLYING MEDICAL CONDITION
The Expert Panel Working Group on MAID Where a Mental Disorder

Is the Sole Underlying Medical Condition
The State of Knowledge on Medical Assistance in Dying
ii Where a Mental Disorder Is the Sole Underlying Medical Condition
THE COUNCIL OF CANADIAN ACADEMIES

180 Elgin Street, Suite 1401, Ottawa, ON, Canada K2P 2K3
Notice: The project that is the subject of this report was undertaken with the approval of
the Board of Directors of the Council of Canadian Academies (CCA). Board members are
drawn from the Royal Society of Canada (RSC), the Canadian Academy of Engineering
(CAE), and the Canadian Academy of Health Sciences (CAHS), as well as from the
general public. The members of the expert panel responsible for the report were selected
by the CCA for their special competencies and with regard for appropriate balance.
This report was prepared for the Government of Canada in response to a request from
the Minister of Health and the Minister of Justice and Attorney General of Canada.
Any opinions, findings, or conclusions expressed in this publication are those of the
authors, the Expert Panel Working Group on MAID Where a Mental Disorder Is the
Sole Underlying Medical Condition, and do not necessarily represent the views of their
organizations of affiliation or employment, or of the sponsoring organizations, Health
Canada and the Department of Justice Canada.
Library and Archives Canada

ISBN: 978-1-926522-49-4 (electronic book) 978-1-926522-48-7 (paperback)
This report should be cited as:

Council of Canadian Academies, 2018. The State of Knowledge on Medical Assistance in
Dying Where a Mental Disorder Is the Sole Underlying Medical Condition. Ottawa (ON):
The Expert Panel Working Group on MAID Where a Mental Disorder Is the Sole
Underlying Medical Condition.
Disclaimer: The internet data and information referenced in this report were correct,
to the best of the CCA’s knowledge, at the time of publication. Due to the dynamic
nature of the internet, resources that are free and publicly available may subsequently
require a fee or restrict access, and the location of items may change as menus and
webpages are reorganized.
© 2018 Council of Canadian Academies

Printed in Ottawa, Canada
This project was made possible with the

support of the Government of Canada
The Council of Canadian Academies iii
The Council of Canadian Academies
The Council of Canadian Academies (CCA) is an independent, not-for-profit

organization that supports independent, science-based, authoritative expert
assessments to inform public policy development in Canada. Led by a Board
of Directors and advised by a Scientific Advisory Committee, the CCA’s work
encompasses a broad definition of science, incorporating the natural, social,
and health sciences as well as engineering and the humanities. CCA assessments
are conducted by independent, multidisciplinary panels of experts from across
Canada and abroad. Assessments strive to identify emerging issues, gaps in
knowledge, Canadian strengths, and international trends and practices. Upon
completion, assessments provide government decision-makers, researchers,
and stakeholders with high-quality information required to develop informed
and innovative public policy.
All CCA assessments undergo a formal report review and are published and
made available to the public free of charge. Assessments can be referred to
the CCA by foundations, non-governmental organizations, the private sector,
or any level of government.
The CCA is also supported by its three founding Academies:
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Founded in 1882, the RSC comprises the Academies of Arts, Humanities and
Sciences, as well as Canada’s first national system of multidisciplinary recognition
for the emerging generation of Canadian intellectual leadership: The College
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and to promote a culture of knowledge and innovation in Canada and with
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The CAE is the national institution through which Canada’s most distinguished
and experienced engineers provide strategic advice on matters of critical
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approximately 740, are committed to ensuring that Canada’s engineering
expertise is applied to the benefit of all Canadians.
iv Where a Mental Disorder Is the Sole Underlying Medical Condition
The Canadian Academy of Health Sciences (CAHS)

CAHS recognizes excellence in the health sciences by appointing Fellows
based on their outstanding achievements in the academic health sciences in
Canada and on their willingness to serve the Canadian public. The Academy
provides timely, informed, and unbiased assessments of issues affecting the
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in 2004, CAHS now has 670 Fellows and appoints new Fellows on an annual
basis. The organization is managed by a voluntary Board of Directors and a
Board Executive.
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@scienceadvice
The Expert Panel on Medical Assistance in Dying v
The Expert Panel on Medical Assistance in Dying

Under the guidance of its Scientific Advisory Committee, Board of Directors,
and the Academies, the CCA assembled the Expert Panel on Medical Assistance
in Dying to undertake this project. Each expert was selected for their expertise,
experience, and demonstrated leadership in fields relevant to this project.
Hon. Marie Deschamps, C.C., Ad. E. (Chair of the Expert Panel), Former
Justice of the Supreme Court of Canada and Adjunct Professor, McGill University
(Montréal, QC) and Université de Sherbrooke (Sherbrooke, QC)
The Expert Panel Working Group on MAID for Mature Minors

Dawn Davies (Working Group Chair), Associate Professor, Department of
Pediatrics, University of Ottawa; Palliative Care Physician, Roger Neilson House/
Children’s Hospital of Eastern Ontario (Ottawa, ON)
Gail Beck, O.Ont., Clinical Director, Youth Psychiatry Program, The Royal
(Ottawa, ON)
Carrie Bourassa, Chair, Northern and Indigenous Health, Health Science North
Research Institute, and Scientific Director, Institute of Indigenous Peoples’
Health – Canadian Institute of Health Research (Sudbury, ON)
Franco A. Carnevale, Professor, Ingram School of Nursing, McGill University
(Montréal, QC)
Joanna Chung, Psychologist, Medical Psychology and Hematology/Oncology/
Bone Marrow Transplant Program, BC Children’s Hospital (Vancouver, BC)
Joan Gilmour, Professor, Osgoode Hall Law School, York University (Toronto, ON)
Hon. Stephen Goudge, Q.C., O.Ont., Counsel, Paliare Roland (Toronto, ON)
Mary Ellen Macdonald, Associate Professor, Faculty of Dentistry, McGill
University (Montréal, QC)
Jean-Pierre Ménard, Ad. E., Lawyer, Ménard, Martin, Avocats (Montréal, QC)
Cheryl Milne, Executive Director, David Asper Centre for Constitutional Rights,
Faculty of Law, University of Toronto (Toronto, ON)
Ubaka Ogbogu, Assistant Professor, Faculties of Law and Pharmacy &
Pharmaceutical Sciences, University of Alberta (Edmonton, AB)
Bryan Salte, Associate Registrar and Legal Counsel, College of Physicians and
Surgeons of Saskatchewan (Saskatoon, SK)
Kimberley Widger, Assistant Professor, Lawrence S. Bloomberg Faculty of
Nursing, University of Toronto; Nursing Research Associate, Paediatric Advanced
Care Team, Hospital for Sick Children (Toronto, ON)
Randi Zlotnik Shaul, Director, Department of Bioethics, The Hospital for Sick
Children (Toronto, ON)
vi Where a Mental Disorder Is the Sole Underlying Medical Condition
The Expert Panel Working Group on Advance Requests for MAID

Jennifer L. Gibson (Working Group Chair), Sun Life Financial Chair in Bioethics
and Director, University of Toronto Joint Centre for Bioethics (Toronto, ON)
Benjamin L. Berger, Professor, Osgoode Hall Law School, York University
(Toronto, ON)
Martha Donnelly, Geriatric Psychiatrist; Associate Professor Emeritus,
Department of Psychiatry, University of British Columbia (Vancouver, BC)
Alika Lafontaine, Medical Director North Zone Indigenous Health, Alberta
Health Services; Assistant Clinical Professor of Medicine, Anesthesiology and
Pain Medicine, University of Alberta; Medical Director, Alignment by Design
Labs (Grande Prairie, AB)
Trudo Lemmens, Professor and Scholl Chair in Health Law and Policy, Faculty
of Law, University of Toronto (Toronto, ON)
Susan MacDonald, Associate Professor, Medicine & Family Medicine, Memorial
University of Newfoundland (St. John’s, NL)
Sheila A.M. McLean, Emeritus Professor, Law & Ethics in Medicine, Glasgow
University (Glasgow, Scotland)
Dorothy Pringle, O.C., FCAHS, Professor Emeritus, Lawrence S. Bloomberg
Faculty of Nursing, University of Toronto (Toronto, ON)
Patricia (Paddy) Rodney, Associate Professor, School of Nursing and Faculty
Associate, W. Maurice Young Centre for Applied Ethics, University of British
Columbia (Vancouver, BC)
Harvey Schipper, Professor of Medicine and Adjunct Professor of Law, University
of Toronto (Toronto, ON)
Samir Sinha, Peter and Shelagh Godsoe Chair in Geriatrics and Director
of Geriatrics, Sinai Health System and University Health Network; Associate
Professor of Medicine, Family & Community Medicine, and Health Policy,
Management and Evaluation, University of Toronto (Toronto, ON)
Tim Stainton, Professor, School of Social Work, University of British Columbia
(Vancouver, BC)
Ross Upshur, Professor, Department of Family & Community Medicine and
Dalla Lana School of Public Health, University of Toronto; Associate Director,
Lunenfeld Tanenbaum Research Institute; Scientific Director, Bridgepoint
Collaboratory for Research and Innovation, Sinai Health System (Toronto, ON)
Agnes van der Heide, Professor and Researcher, Erasmus University Medical
Center Rotterdam (Rotterdam, the Netherlands)
The Expert Panel on Medical Assistance in Dying vii
The Expert Panel Working Group on MAID Where a Mental

Disorder Is the Sole Underlying Medical Condition
Kwame McKenzie (Working Group Chair), CEO, Wellesley Institute; Professor
of Psychiatry, University of Toronto; Medical Director, Health Equity, Centre
for Addiction and Mental Health; Commissioner, Ontario Human Rights
Commission (Toronto, ON)
Melissa K. Andrew, Associate Professor, Medicine (Geriatrics), Dalhousie
University and Nova Scotia Health Authority (Halifax, NS)
Jennifer A. Chandler, Bertram Loeb Research Chair, Full Professor, Centre for
Health Law, Policy and Ethics, Faculty of Law, University of Ottawa (Ottawa, ON)
Pierre Deschamps, C.M., Member of Research Group on Health and Law,
McGill University (Montréal, QC)
Jocelyn Downie, C.M., FRSC, FCAHS, University Research Professor, Faculties
of Law and Medicine, Dalhousie University (Halifax, NS)
Martin Drapeau, Professor, Counselling Psychology and Psychiatry, McGill
Colleen M. Flood, FRSC, FCAHS, Director, Centre for Health Law Policy and
Ethics; Professor and Research Chair in Health Law and Policy, University of
Ottawa (Ottawa, ON)
Arthur W. Frank, FRSC, Professor Emeritus, Department of Sociology, University
of Calgary (retired) (Calgary, AB); Professor II, VID Specialized University
(Oslo, Norway)
K. Sonu Gaind, Chief of Psychiatry/Medical Director of Mental Health, Humber
River Hospital; Associate Professor, University of Toronto; Board Member,
World Psychiatric Association (Toronto, ON)
Mona Gupta, Associate Professor and Psychiatrist, Centre hospitalier de
l’Université de Montréal (CHUM) (Montréal, QC)
Scott Y.H. Kim, Senior Investigator, Department of Bioethics, National Institutes
of Health (Bethesda, MD)
Brian L. Mishara, Director, Centre for Research and Intervention on Suicide,
Ethical Issues, and End-of-Life Practices (CRISE), Université du Québec à
Montréal (Montréal, QC)
Tanya Park, Assistant Professor, Faculty of Nursing, University of Alberta
(Edmonton, AB)
Suzanne Stewart, Director, Waakebiness-Bryce Institute for Indigenous Health,
University of Toronto (Toronto, ON)
The CCA also recognizes the important contributions of Yves Beauchamp,
Vice-Principal, Administration and Finance, McGill University (Montréal, QC).
viii Where a Mental Disorder Is the Sole Underlying Medical Condition
Message from the Chairs
Medical assistance in dying (MAID) has been a topic of public debate in Canada
for over 50 years. In 2015, the Supreme Court of Canada opened a new chapter
in the debate with its Carter ruling, which was followed 18 months later by
the passage of Bill C-14, An Act to Amend the Criminal Code and to Make Related
Amendments to Other Acts (Medical Assistance in Dying). This unprecedented change
in the legal landscape — welcomed by some and repudiated by others — reflects
an evolving conversation about death and dying that is uniquely Canadian.
This conversation continues through the work of the Expert Panel on Medical
Assistance in Dying, convened by the Council of Canadian Academies (CCA).
It has been a privilege to serve over the past 18 months as Chairs. More than
40 experts from Canada and abroad, with diverse disciplinary and professional
backgrounds, were convened as the Expert Panel while an additional 35 national
and international experts served as independent Report Reviewers. The Panel
undertook an evidence-based assessment of the state of knowledge surrounding
three topics specified in the Act for independent review: MAID for mature
minors, advance requests for MAID, and MAID where a mental disorder is the
sole underlying medical condition. The three reports reflect a broad range of
knowledge, experience, and perspective among relevant healthcare professions,
diverse academic disciplines, advocacy groups, Indigenous Elders, and from
regions where MAID is permitted.
The Expert Panel’s work could not have been accomplished without the time
and dedication of so many. First, we would like to thank the Panel members
themselves, whose exceptional commitment and expert contributions ensured
a fair assessment of the evidence. We would also like to express our gratitude
to the Report Reviewers, whose detailed and constructive comments improved
the depth and quality of each report. Special thanks go to the 59 groups and
organizations across Canada affected by or involved in MAID, which responded
to our Call for Input and submitted evidence, insight, and stories to enrich
the Panel’s work. Finally, on behalf of all Panel members, we would like to
thank the CCA staff, who worked tirelessly to bring their tremendous research
expertise, professionalism, dedication, and good humour to this project, under
the guidance of Dr. Eric Meslin, CCA President and CEO.
Message from the Chairs ix
These reports reflect a particular moment in Canada’s history, in the breadth

and availability of evidence, and in the evolution of thinking and practice
related to MAID. We invite the Canadian public as well as Parliamentarians to
engage in a wider discussion about MAID in the weeks and months following
release of these reports. It is our hope that the Panel’s reports will foster this
Canadian conversation.
With our thanks for this opportunity to serve,
Marie Deschamps, C.C., Ad. E.

Chair, Expert Panel on Medical Assistance in Dying
Dawn Davies
Chair, Expert Panel Working Group on MAID for Mature Minors
Jennifer L. Gibson
Chair, Expert Panel Working Group on Advance Requests for MAID
Kwame McKenzie
Chair, Expert Panel Working Group on MAID Where a Mental Disorder Is the
Sole Underlying Medical Condition
x Where a Mental Disorder Is the Sole Underlying Medical Condition
Message from the President and CEO
Every CCA assessment focuses on a topic of importance to the Sponsor who

requested it and to those who await the Expert Panel’s findings. Each is unique
in its own way. But when the Minister of Health and Minister of Justice referred
MAID-related questions to the CCA, we knew we were undertaking one of our
most challenging assignments. For obvious reasons, policy topics about how
people live and die are especially difficult because they speak to fundamental
concepts of human dignity, autonomy, liberty, and suffering; they remind us
of long-standing conversations and debates about the rights of patients and
the duties of clinicians; and they reflect diverse social norms and cultural
perspectives. With respect to MAID for mature minors, advance requests for
MAID, and MAID where a mental disorder is the sole underlying medical
condition, the task is especially daunting given that domestic and international
experience is limited and the existing published literature cannot provide a
complete picture of MAID as experienced by patients, families, communities,
and healthcare practitioners.
This assessment required care, sensitivity, and wisdom to identify what is

known and what gaps in knowledge remain to be filled. While no assessment
can include every possible perspective, the CCA was mindful of the need to
gather abundant expertise for this project: we invited specialists with clinical,
legal, and regulatory expertise to the table; we sought authoritative scholars
and practitioners from the fields of law, medicine, nursing, mental health,
bioethics, anthropology, and sociology; and we included input from Indigenous
elders. Drawing on experts from across Canada and other countries, the CCA
established a panel of 43 individuals who together reflected the breadth of
knowledge and experience required to answer the Sponsors’ questions.
Leadership for this Expert Panel was provided by the Honourable Marie
Deschamps, our overall Panel Chair, and by three Working Group Chairs:
Dr. Dawn Davies, Prof. Jennifer Gibson, and Dr. Kwame McKenzie. I am grateful
to all four Chairs for their dedication and commitment to ensuring these
reports reflect the considered views and deliberations of Panel members. I am
particularly appreciative of the commitment of every Panel member, each of
whom volunteered their time in the service of this important task.
Message from the President and CEO xi
I also wish to express sincere thanks to the three Academies — the Royal Society
of Canada, the Canadian Academy of Engineering, and the Canadian Academy
of Health Sciences — for their support and expert assistance; to the CCA’s
Board of Directors and Scientific Advisory Committee for their advice and input;
and to our dedicated staff for their hard work in support of the Expert Panel.
Finally, I would like to thank the Minister of Health and Minister of Justice for
entrusting the CCA with the responsibility to undertake an assessment of such
importance to Canada and Canadians. The products of the Expert Panel’s work
are now in the hands of the Government of Canada, as requested, and will
be widely disseminated. It is our hope that this assessment will inform policy
discussion and public discussion in Canada and abroad.
Eric M. Meslin, PhD, FCAHS

President and CEO, Council of Canadian Academies
xii Where a Mental Disorder Is the Sole Underlying Medical Condition
Acknowledgements
Over the course of its deliberations, the Panel reached out to many individuals
and organizations that provided valuable evidence, information, and assistance
in the development of the reports. The Panel wishes to thank the following
people for their participation in an early planning meeting: Jeff Blackmer,
Canadian Medical Association; Jennifer A. Chandler, University of Ottawa; Dawn
Davies, University of Alberta; Jocelyn Downie, C.M., FRSC, FCAHS, Dalhousie
University; Catherine Frazee, O.C., Ryerson University; Jennifer L. Gibson,
University of Toronto; Jean Gray, C.M., FCAHS, Dalhousie University; Douglas
Ruth, FCAE, University of Manitoba; Janet Storch, University of Victoria; and
Randi Zlotnik Shaul, The Hospital for Sick Children.
Special thanks are extended to Elders Dot Beaucage-Kennedy, Jacqui Lavalley,

Betty McKenna, Roberta Price, and Ted Quewezance for sharing their knowledge
and wisdom with the Panel.
The Panel would also like to recognize the following individuals and organizations:
David J. Wright of McGill University for so generously sharing his knowledge; Félix
Hébert, Mary Shariff, and Daniel Weinstock for their legal expertise; Metamorfose
Vertalingen and Textualis for translation services; and all organizations that
provided submissions as part of the Call for Input.
Project Staff of the Council of Canadian Academies xiii
Project Staff of the Council of Canadian Academies
Assessment Team: Tijs Creutzberg, Director of Assessments

Janet W. Bax, Project Director
Jill Watkins, Project Director
Erin Bassett, Research Associate
Jennifer Bassett, Research Associate
Amanda Bennett, Research Associate
Rebecca Chapman, Research Associate
Madison Downe, Project Coordinator
Andrea Hopkins, Lead, Assessment Coordination &
Planning
Teresa Iacobelli, Research Associate
Matthew Ivanowich, Researcher
Anita Melnyk, Research Associate

With Assistance from: Jonathan Harris, Research Associate, CCA
Marc Dufresne, Report Design, CCA
and: Jody Cooper, Editorial Consultant

Clare Walker, Editorial Consultant
Dany Gagnon and Anne-Marie Mesa, Certified
translators, Translation English-French
xiv Where a Mental Disorder Is the Sole Underlying Medical Condition
Report Review
These reports were reviewed in draft form by reviewers selected by the CCA
for their diverse perspectives and areas of expertise.
The Report Reviewers assessed the objectivity and quality of the reports. Their
submissions — which will remain confidential — were considered in full by
the Panel, and many of their suggestions were incorporated into the reports.
They were not asked to endorse the conclusions, nor did they see final report
drafts before release. Responsibility for the final content of these reports rests
entirely with the authoring Expert Panel Working Group and the CCA.
The CCA wishes to thank the following individuals for their review of these
reports:
Reviewers of the MAID for Mature Minors Report
Priscilla Alderson, Professor Emerita of Childhood Studies, University College

London (London, United Kingdom)
Cécile Bensimon, Director, Ethics and Professional Affairs, Canadian Medical
Association (Ottawa, ON)
Marie-Claude Grégoire, FRCPC, Physician, Perioperative Anesthesiology
Clinical Trials Group (PACT), IWK Health Centre; Assistant Professor, Dalhousie
University (Halifax, NS)
Irma Hein, Child and Adolescent Psychiatrist; Senior Researcher, De
Bascule Academic Centre for Child and Adolescent Psychiatry (Amsterdam,
the Netherlands)
Stan Kutcher, FCAHS, Professor of Psychiatry, Dalhousie University (Halifax, NS)
Aria Laskin, Lawyer (Vancouver, BC)
Constance MacIntosh, Associate Professor and Viscount Bennett Professor of
Law, Schulich School of Law, Dalhousie University (Halifax, NS)
Chantelle Richmond, Professor and Canada Research Chair in Indigenous
Health and Environment, Western University (London, ON)
Erica K. Salter, Associate Professor, Health Care Ethics and Pediatrics, Saint Louis
University (St. Louis, MO)
Hal Siden, Medical Director, Canuck Place Children’s Hospice and BC Children’s
Hospital (Vancouver, BC)
Sigrid Sterckx, Professor of Ethics and Social & Political Philosophy, Ghent
University (Ghent, Belgium)
Report Review xv
Reviewers of the Advance Requests for MAID Report
B. Lynn Beattie, Professor Emerita, Department of Medicine, University of

British Columbia (Vancouver, BC)
Gina Bravo, Professor, Université de Sherbrooke (Sherbrooke, QC)
Catherine Frazee, O.C., Professor Emerita, Ryerson University (Toronto, ON)
Linda Ganzini, Professor of Psychiatry and Medicine, Oregon Health & Science
University (Portland, OR)
Chris Gastmans, Professor, University of Leuven (Leuven, Belgium)
Rosie Harding, Chair in Law and Society, Birmingham Law School, University
of Birmingham (Birmingham, United Kingdom)
Philip Hébert, Professor Emeritus, Department of Family & Community
Medicine, University of Toronto (Toronto, ON)
Janet Storch, Professor Emeritus, University of Victoria (Victoria, BC)
Tamara Sussman, Associate Professor, McGill University (Montréal, QC)
Nele van den Noortgate, Head, Geriatric Department, Ghent University
Hospital (Ghent, Belgium)
Eric Wasylenko, Medical Director, Health System Ethics & Policy, Health
Quality Council of Alberta; Clinical Associate Professor, Division of Palliative
Medicine, Department of Oncology, Cumming School of Medicine, University
of Calgary (Calgary, AB)
Reviewers of the MAID Where a Mental Disorder Is the Sole

Underlying Medical Condition Report
Kenneth Chambaere, Assistant Professor, End-of-Life Care Research Group,

Vrije Universiteit Brussels and Ghent University (Brussels, Belgium)
Marianne Dees, Senior Researcher, Department of Primary and Community
Care, Radboud Institute for Health Sciences, Radboud University Medical
Centre (Nijmegen, the Netherlands)
Judy Illes, FRSC, FCAHS, Professor of Neurology and Canada Research Chair
in Neuroethics, University of British Columbia (Vancouver, BC)
Rod McCormick, Professor and BCIC Chair in Indigenous Health, Thompson
Rivers University (Kamloops, BC)
Bregje Onwuteaka-Philipsen, Professor of End-of-Life Research, Department
of Public and Occupational Health, Amsterdam University Medical Centre
(Amsterdam, the Netherlands)
xvi Where a Mental Disorder Is the Sole Underlying Medical Condition
Elizabeth Peter, Professor, Lawrence S. Bloomberg Faculty of Nursing and

Joint Centre for Bioethics, University of Toronto (Toronto, ON)
Geoffrey Reaume, Associate Professor, Critical Disability Studies Graduate
Program, York University (Toronto, ON)
Tom Shakespeare, Professor of Disability Research, University of East Anglia
(Norwich, United Kingdom)
Scott Theriault, Deputy Head, Department of Psychiatry, Dalhousie University
(Halifax, NS)
Amy Zarzeczny, Associate Professor, University of Regina (Regina, SK)
Special thanks are extended to David Orentlicher, Cobeaga Law Firm Professor
of Law and Co-Director, University of Nevada – Las Vegas William S. Boyd
School of Law (Las Vegas, NV) and Joris Vandenberghe, Psychiatrist, University
Hospitals UZ Leuven and Professor, University of Leuven – KU Leuven (Leuven,
Belgium).
Report Review Monitors
The report review procedure was monitored on behalf of the CCA’s Board of
Directors by three members of the CCA’s Scientific Advisory Committee. The
MAID Where a Mental Disorder Is the Sole Underlying Medical Condition report
review was monitored by David Castle, Vice-President Research, University of
Victoria; the Advance Requests for MAID report by Malcolm King, FCAHS,
Professor, University of Saskatchewan; and the MAID for Mature Minors report
by Stuart MacLeod, FCAHS, Professor Emeritus (Pediatrics), University of
British Columbia.
The role of the report review monitor is to ensure that the Panel gives full and
fair consideration to the submissions of the reviewers. The CCA Board authorizes
public release of an expert panel report only after the report review monitors
confirm that the CCA’s report review requirements have been satisfied. The
CCA thanks Drs. Castle, King, and MacLeod for their diligent contributions
as report review monitors.
List of Acronyms and Abbreviations Used in the Reports xvii
List of Acronyms and Abbreviations Used in the Reports
ACP Advance Care Planning

AED Advance Euthanasia Directive
CAMAP Canadian Association of MAID Assessors and Providers
CAMH Centre for Addiction and Mental Health
CAYAC Child and Youth Advisory Council at the Alberta Children’s Hospital
CCB Consent and Capacity Review Board of Ontario
CFCEE Commission fédérale de Contrôle et d’Évaluation de l’Euthanasie
(Belgium)
CNCE Commission Nationale de Contrôle et d’Évaluation (Luxembourg)
CPS Canadian Paediatric Society
CPST Continuous Palliative Sedation Therapy
CSPCP Canadian Society of Palliative Care Physicians
DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
EAS Euthanasia and Assisted Suicide
IRER Immigrant, Refugee, Ethnocultural, and Racialized
MAID MD-SUMC Medical Assistance in Dying Where a Mental Disorder is
the Sole Underlying Medical Condition
NVVP Nederlandse Vereniging voor Psychiatrie (Dutch Psychiatric Association)
PAD Physician Aid in Dying
PAS Physician-Assisted Suicide
PPC Pediatric Palliative Care
RTE Regionale Toetsingscommissies Euthanasie (Regional Euthanasia
Review Committees), the Netherlands
SCEN Steun en Consultatie bij Euthanasie in Nederland (Support and
Consultation on Euthanasia in the Netherlands)
SDM Substitute Decision Maker
SLK Levenseindekliniek (End-of-Life Clinic), the Netherlands
VPS Vulnerable Persons Standard
VSED Voluntary Stopping of Eating and Drinking
VVP Vlaamse Vereniging voor Psychiatrie (Flemish Psychiatric Association)
xviii Where a Mental Disorder Is the Sole Underlying Medical Condition
Table of Contents
1 Introduction............................................................................. 1
1.1 The Charge.......................................................................................2
1.2 Scope.................................................................................................4
1.3 The Expert Panel..............................................................................4
1.4 Terminology......................................................................................5
1.5 Evidence Considered........................................................................6
1.6 How to Read this Report................................................................12
2 MAID in Canada: Historical and

Current Considerations......................................................... 13
2.1 How Did We Get Here?..................................................................14
2.2 Implementation of MAID in Canada.............................................20
2.3 Provision of Healthcare in Canada................................................26
2.4 Healthcare Decision-Making..........................................................30
2.5 Chapter Summary...........................................................................32
3 Mental Disorders in Canada................................................. 33

3.1 The Concept of Mental Disorder...................................................36
3.2 Suicide ............................................................................................41
3.3 Prevalence and Socio-Economic/Demographic Correlates
of Mental Disorders, and Access to Mental
Healthcare in Canada.....................................................................43
3.4 Indigenous People and Mental Health..........................................49
3.5 Other Specific Populations and Mental Health............................50
3.6 Legal Landscape for Mental Health and MAID............................54
3.7 Knowledge Gaps..............................................................................59
4 Mental Disorders and MAID — Key Issues.......................... 61

4.1 Issues Regarding Current Eligibility Criteria.................................63
4.2 Suicide and MAID MD-SUMC........................................................84
4.3 Vulnerability and Autonomy..........................................................96
4.4 Mental Healthcare and Treatment...............................................102
4.5 Knowledge Gaps............................................................................107
Table of Contents xix
5 Assisted Dying for People with

Mental Disorders Worldwide............................................. 109
5.1 Why Look to International Evidence on
MAID MD-SUMC?.........................................................................111
5.2 The International Legal Landscape.............................................113
5.3 Sources and Quality of Evidence Relating
to Psychiatric EAS.........................................................................120
5.4 Psychiatric EAS: Frequency and Trends in
the Netherlands and Belgium......................................................122
5.5 Characteristics of Individuals Who
Request/Receive Psychiatric EAS.................................................129
5.6 Evaluation of Patients Requesting Psychiatric EAS.....................132
5.7 How Psychiatric EAS is Monitored
in the Netherlands and Belgium..................................................141
5.8 Implications of the International Data........................................143
5.9 Knowledge Gaps............................................................................145
6 Potential Implications of Prohibiting or

Permitting More MAID MD-SUMC..................................... 147
6.1 Potential Implications...................................................................149
6.2 Speculative Implications...............................................................167
6.3 Unique Considerations for Specific Populations........................171
6.4 Potential Safeguards.....................................................................176
6.5 Conclusion....................................................................................188
7 Conclusion........................................................................... 191
7.1 Answering the Charge..................................................................193
7.2 Final Thoughts..............................................................................196
References...................................................................................... 199
Appendix A..................................................................................... 239
Appendix B..................................................................................... 243

Chapter 1 Introduction 1
1
Introduction
• The Charge
• Scope
• The Expert Panel
• Terminology
• Evidence Considered
• How to Read this Report

2 Where a Mental Disorder Is the Sole Underlying Medical Condition
1 Introduction
Canada has become one of a small number of jurisdictions to allow some

form of medical assistance in dying (MAID). The Supreme Court of Canada’s
Carter v. Canada decision in 2015 held that an absolute prohibition against
physician-assisted death was unjustifiable (SCC, 2015). The landmark ruling
was followed by the passage of Bill C-14, An Act to Amend the Criminal Code and
to Make Related Amendments to Other Acts (Medical Assistance in Dying). The Act
amended the Criminal Code to allow for the provision of MAID under specific
circumstances (GC, 2016b).
The passage of the Act and the practice of MAID in Canada, however, have
not settled public debate. Among the issues under discussion are eligibility
criteria and procedural safeguards in the legislation, including the criteria that
people under the age of 18 are not eligible for MAID; that it is not possible for
a person to consent to MAID through an advance request; and that very few
people with a mental disorder as their sole underlying medical condition will
meet eligibility criteria for MAID (e.g., that natural death must be reasonably
foreseeable). Parliament has called for one or more independent reviews to
study the question of prohibiting or permitting MAID to people in the above
groups (Section 9.1 of the Act).
To meet their obligation, the Ministers of Health and Justice, on behalf of

Health Canada and the Department of Justice Canada (the Sponsors), asked
the Council of Canadian Academies (CCA) to conduct independent, evidence-
informed reviews of the state of knowledge on MAID as it relates to these three
topic areas (mature minors, advance requests, and where a mental disorder
is the sole underlying medical condition). The reviews were initiated with a
public announcement in December 2016.
1 . 1 THE C HA R G E
The objective of the reviews, herein referred to as the reports, was to gather
and assess information and evidence relevant to the three topic areas in order
to inform a national dialogue among the Canadian public, and between the
public and decision-makers. The Sponsors therefore asked the CCA to answer
the following general questions:
Main Question
What is the available evidence on, and how does it inform our understanding
of, medical assistance in dying (MAID) in the case of mature minors, advance
requests, and where mental illness is the sole underlying medical condition,
given the clinical, legal, cultural, ethical, and historical context in Canada?
General Sub-Questions
What are the potential implications for individuals and other affected persons,
including their families, care providers, and health professionals, related to
MAID for the three topic areas?
What are the potential impacts on society of permitting or prohibiting requests

for MAID for the three topic areas?*
What are the potential risks and safeguards that might be considered related to
MAID for the three topic areas?
What are the relevant gaps in domestic and international knowledge and research
related to MAID for the three topic areas?
*E.g., Suicide prevention strategies and medical responses; availability and efficacy
of palliative care; dementia-related and mental health services and supports; risks
to vulnerable populations; discrimination and stigma related to chronological age,
dementia and related illnesses, and mental illness; and risks of inducements.
The charge also included sub-questions specific to the three topic areas:
Requests for MAID by Mature Minors

What is the impact of chronological age on the legal capacity to request and
consent to MAID?
What are the unique considerations related to mature minors requesting MAID
(e.g., mature minors vs. adults and MAID vs. other healthcare decisions)?
Advance Requests for MAID

How is an advance request for MAID similar to or different from advance
directives for healthcare under existing provincial/territorial regimes?
What are the unique considerations to be taken into account depending on when
an advance request is made?**
** That is: 1) before diagnosis; 2) after diagnosis but before onset of suffering; 3) after
all of the eligibility criteria and procedural safeguards have been met, except for the
10 day waiting period and the reconfirmation immediately prior to provision of MAID.
Requests for MAID Where Mental Illness Is the Sole Underlying Medical
Condition***
What is the impact of mental illness in its different forms on an individual’s
legal capacity to request and consent to MAID?
What are the unique considerations related to individuals living with mental
illness (including mature minors) requesting MAID where the mental illness is
the sole underlying medical condition?****
*** For certainty, the study is concerned with requests where mental illness is the
sole underlying medical condition and does not include circumstances where a
person with a mental illness is eligible under the existing law.
**** Both in communities or institutions.
1 . 2 SCOPE
The reports address the questions set out in the charge. They focus on what
is known and not known about MAID as it relates to mature minors, advance
requests, and a mental disorder as the sole underlying medical condition. The
reports do not provide recommendations to governments. It is also important to
note that the reports do not evaluate the provisions enacted by Canada’s MAID
legislation; a formal review of MAID is required at year five (see Section 10 of
the Act). Nor do they revisit the legal arguments and evidence for allowing or
prohibiting MAID in general.
1 . 3 THE E XP E RT PANE L
To address its charge, the CCA assembled a multidisciplinary panel of 43 experts

from Canada and abroad (the Panel), divided into three Working Groups. Each
Working Group focused on one of the three topic areas. The Panel’s expertise
covered academic, clinical, legal, and regulatory fields from the disciplines
of medicine, nursing, law, bioethics, psychology, philosophy, epidemiology,
anthropology, and sociology. Each member served on the Panel on a pro bono
basis as an informed individual, rather than as a representative of a particular
community, discipline, organization, or region. The Panel met in person six
times from May 2017 through to July 2018 at various locations across Canada.
Panel members convened both in plenary and within their respective Working
Groups to deliberate over the evidence.
The Panel also organized three parallel sessions to discuss aspects of the charge
that intersected with more than one topic area. These sessions examined the
social determinants of health relevant to all three topic areas, the relationship
between advance requests and mental disorders, and the intersection between
mental disorders and mature minors. The result of these sessions informed
each of the reports. The Working Groups and various subgroups also held
discussions via teleconference as required to advance the reports between
in-person meetings.
1 .4 TE R MI NOL OGY
Medical Assistance in Dying

For the purposes of the reports, and consistent with the federal legislation,
the Panel uses the term medical assistance in dying (MAID), which, as defined in
the legislation, means:
(a) the administering by a medical practitioner or nurse practitioner of a

substance to a person, at their request, that causes their death; or
(b) the prescribing or providing by a medical practitioner or nurse practitioner

of a substance to a person, at their request, so that they may self-administer
the substance and in doing so cause their own death.
(GC, 2016b)
The gathered evidence often used alternative words and phrases, including
euthanasia, assisted suicide, physician-assisted suicide, physician-assisted death, or
medical aid in dying. When referring to evidence from other jurisdictions, the
reports use the terminology common to the relevant jurisdiction. A table of
legal terminology with notes on common usage in other regions is available
in Appendix A.
Mature Minor
A minor is a person under the age of majority (18 or 19 depending on the province
or territory). A mature minor is a minor who has the capacity to understand
and appreciate the nature and consequences of a decision. The Panel’s use of
further terminology and nuances related to minors, such as children, adolescents,
youth, and adults, are explained in The State of Knowledge on Medical Assistance
in Dying for Mature Minors.
Advance Requests for MAID and Advance Directives

The Panel defines an advance request for MAID (AR for MAID) as a request for
MAID, created in advance of a loss of decision-making capacity, intended to be
acted upon under the circumstances outlined in the request after the person
has lost decisional capacity.
ARs for MAID should be distinguished from provincially and territorially

regulated advance directives, which are documents that “allow a decisionally-
capable individual either to designate someone to make decisions about health
care on his or her behalf, or to specify types of treatment to be accepted or
rejected, should the need arise, or both,” in the event that the individual loses
decision-making capacity (Gilmour, 2017). The State of Knowledge on Advance
Requests for Medical Assistance in Dying explores in detail the possible relationship
between ARs for MAID and advance directives.
Mental Disorder and Mental Illness

MAID legislation and the charge use the term mental illness. However, the
Working Group chose to use the term mental disorder to be consistent with
current clinical and legal practice. Mental disorder is the term used in the two
primary classification systems in psychiatry: the World Health Organization’s
International Statistical Classification of Diseases and Related Health Problems (ICD-
10) (WHO, 2016) and the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) (APA, 2013).
1 . 5 E VI D E N C E C ONS I DE RE D
The CCA has a long-established approach for convening experts and assessing
evidence. Throughout the assessment process, the Panel was asked to identify
the range of knowledge and evidence relevant to the charge, examine this body
of evidence, and interpret it in the form of findings. The Panel recognizes that
the breadth of experience is limited, as a small number of jurisdictions permit
some form of MAID and fewer still permit MAID in the three topic areas.
Given the complex, interdisciplinary nature of the topics, the Panel recognized
the importance of interpreting evidence broadly and included empirical evidence
such as peer-reviewed research and grey literature, normative evidence such as
bioethical argumentation, and other forms of evidence such as lived experiences.
To this end, the Panel identified and assessed evidence that was found in, but
was not limited to, peer-reviewed publications from health disciplines, ethics,
social sciences, humanities, and law; professional standards and guidelines;
regulatory, legislative, and compliance materials; policy documents; and media
reports.
Panel members identified evidence in multiple ways. For example, they drew
on their respective disciplinary expertise to identify important evidence in their
fields, conducted literature searches, and reviewed responses from the CCA’s Call
for Input (Section 1.5.1). Evidence gathering also included conversation with
Indigenous Elders (Section 1.5.2). Literature searches were carried out using
search terms that reflected the diversity of terminology that describes MAID
domestically and internationally (Appendix A), as well as related concepts and
practices. Literature searches were iterative, informed by Panel deliberations,
and included examining literature cited by relevant articles and reports.
The Panel acknowledges a number of challenges and limitations associated with

assessing evidence from such diverse sources. In addition to varying quality and
availability of research, disciplines may also differ in the evidentiary standards
they apply and in the methods of establishing those standards. It was important,
therefore, for the Panel to consider the value and quality of the evidence from
the standards of their respective disciplines.
The Panel also recognizes that different types of evidence are not necessarily
commensurable, and cannot be ordered within a single hierarchy of credibility.
Ethical argumentation, empirical medical research, traditional knowledge,
and lived experiences, for example, each give understanding, perspective,
and nuance to MAID-related issues that no one type of evidence can provide
on its own. Moreover, the Panel recognizes that not all questions that matter
can be addressed by empirical research; in some cases, an anecdote conveying
meaning through lived experience or an argument based on logic may be more
relevant to the question.
To the extent that the evidence allowed, the Panel also considered how MAID
legislation regarding the three topic areas might impact diverse groups of
people. Panel deliberations therefore considered gender, race, ethnicity, ability,
socio-economic status, and other factors affecting the determinants of health,
including healthcare access and delivery of services.
The reports are a synthesis of knowledge available to the Panel through

the academic and policy literature, the CCA’s Call for Input, and its diverse
interdisciplinary and professional expertise. The Panel’s findings provide a
lens into what is currently known about MAID with respect to the three topics
at issue. They also shed light on relevant values for MAID policy in Canada,
including how differences in values may lead to differences in the interpretation
of evidence. The final text is the product of a collective effort to engage with
these evidentiary and evaluative inputs to address the charge questions. Each
report reflects the general view of its Working Group members even if on
some points unanimity could not be established. In some situations, even after
consideration of available data and Panel discussions, agreement could not
be achieved and significant differences of opinion remained, reflecting the
complex and conflicted nature of the issues being reviewed; in those instances,
such disagreement is reflected in the reports.
1.5.1 Call for Input

As part of the Panel’s evidence-gathering activity, a Call for Input was carried
out by the Panel over a three-month period beginning in July 2017. In addition
to inviting written input from 500 groups and organizations across Canada
affected by, or involved in, MAID, the Call for Input was made available online
to any interested organizations. Specifically, the Panel asked organizations to:
(i) describe their main issues concerning requests for MAID in the three topic
areas under study; and (ii) submit, or provide links to, any knowledge they
would like the Panel to consider. The CCA received 59 submissions from a wide
variety of organizations in the areas of advocacy, medicine, nursing, pharmacy,
social work, law, and religion (Box 1.1).
Call for Input submissions were shared with Panel members and reviewed to
identify issues related to the three topic areas. Call for Input submissions also
identified a range of evidence, including professional guidelines and codes of
ethics, additional peer-reviewed articles, surveys of membership of professional
bodies, and lived experience testimony, not previously available to, or identified
by, the Panel. Where relevant, these sources were included in the body of
evidence assessed by the Panel.
1.5.2 Indigenous Elders Circle

An Elders Circle, facilitated by Indigenous Panel members, was held in February
2018 to provide insight into Indigenous perspectives on MAID, particularly
with respect to the three topic areas. Six Elders from Métis and First Nations
in British Columbia, Saskatchewan, Manitoba, and Ontario offered their
knowledge of end-of-life attitudes, practices, issues, and concerns. Notably,
the Elders felt that Indigenous Peoples had not been consulted on the issue
of MAID. The Panel recognizes that the Elders Circle was limited in scope and
representation, and does not constitute consultation with Indigenous Peoples
on the topic of MAID. This remains a significant knowledge gap.
1.5.3 International Experience

The Panel considered the experiences and evidence from other countries that
allow some form of assisted dying. In cases where access to relevant documents
from other countries was impeded by language, professional translators were
engaged.
Assisted dying is legal or partially decriminalized in a small number of jurisdictions

(Figure 1.1); areas that allow assisted deaths do so with specific access criteria
and safeguards. The Panel considered and assessed critically the international
evidence in light of the Canadian healthcare environment, its unique geography
and history, and the contemporary political and social policy context within
which the MAID conversation is occurring.
Box 1.1
Organizations That Made a Formal Submission to
the CCA’s Call for Input
• Addictions and Mental Health Ontario • College of Physicians and Surgeons of
• Alberta College of Social Workers Ontario
• Alzheimer Society of British Columbia • College of Registered Nurses of Manitoba
• Alzheimer Society of Nova Scotia • College of Registered Psychiatric Nurses of
• Association for Reformed Political Action Manitoba
• Association médicale du Québec • Community Health Nurses of Canada
• Association of Registered Nurses of British • Covenant Health
Columbia • Dying with Dignity Canada
• Autism Canada • Empowerment Council
• British Columbia College of Social Workers • Evangelical Fellowship of Canada
• British Columbia Humanist Association • Federation of Medical Regulatory
• Canadian Association for Community Authorities of Canada
Living • Institut de planification des soins
• Canadian Association of MAID Assessors • Manitoba Provincial MAID Clinical Team
and Providers • National Association of Pharmacy
• Canadian Bar Association Regulatory Authorities
• Canadian Coalition for the Rights of • Nova Scotia College of Pharmacists
Children • Nurse Practitioner Association of Canada
• Canadian Federation of Catholic • Nurse Practitioner Association of Manitoba
Physicians’ Societies • Ontario College of Social Workers and
• Canadian Medical Association Social Service Workers
• Canadian Medical Protective Association • Ontario Psychiatric Association
• Canadian Mental Health Association • Ontario Shores Centre for Mental Health
• Canadian Physicians for Life Sciences
• Canadian Psychiatric Association • Ottawa Catholic Physicians’ Guild
• Canadian Society of Palliative Care • Physicians’ Alliance Against Euthanasia
Physicians • REAL Women of Canada
• CARP • Right to Die Society of Canada
• Catholic Civil Rights League • Salvation Army
• Catholic Health Alliance of Canada • St. Joseph’s Health Care London
• Centre for Addiction and Mental Health • The Hospital for Sick Children
• Christian Legal Fellowship • Toronto Catholic Doctors’ Guild
• Christian Medical and Dental Society of • Toujours Vivant-Not Dead Yet
Canada • University Health Network
• Collège des médecins du Québec • University of Toronto Joint Centre for
• College of Licensed Practical Nurses of Bioethics MAID Implementation Task Force,
Manitoba MAID Advance Request Working Group
• West Coast Assisted Dying
10
Canada *
Montana
Washington
Oregon
California Washington D.C.
Colorado United States Netherlands
Hawaii Germany
Belgium
Colombia
Luxembourg
Switzerland
Australia
Victoria Assisted Dying Permitted
Mature Minors
Advance Request
Mental Disorders
Data Source: Bruns, 2016; GC, 2016b; Gov. of Belgium, 2002; Gov. of CA, 2015; Gov. of CO, 2016; Gov. of Colombia, 2015; Gov. of DC, 2016; Gov. of Germany, 1998; Gov. of HI, 2018; Gov. of
Luxembourg, 2009; Gov. of the Netherlands, 2002; Gov. of OR, 1997; Gov. of Switzerland, 1942; Gov. of Victoria, 2017; Gov. of VT, 2013; Gov. of WA, 2009; Supreme Court of the State of Montana, 2009
Figure 1.1 Map of the World Showing Places Where Some Form of Assisted Dying is Allowed
This figure represents the understanding of the Expert Panel regarding the status of assisted dying worldwide, given the available knowledge at the time this report
was written. Jurisdictions vary in terms of the legal mechanism by which assisted dying is allowed (e.g., through legislation or a court decision), the form of assisted
dying that is permitted (e.g., self-administration or physician administration of a lethal substance), and the specific eligibility criteria (e.g., requirement of a terminal
illness or a minimum age). For additional information, see Appendix A. The symbols on the map indicate the countries in which assisted dying can be accessed by
mature minors, through advance requests, or by people with a mental disorder as their sole underlying medical condition.
Where a Mental Disorder Is the Sole Underlying Medical Condition
*To access assisted dying in Canada, including for a mental disorder, death must be reasonably foreseeable, but this is not a requirement in Belgium, Luxembourg,
or the Netherlands.
Rates of uptake vary considerably among, and even within, regions; in U.S. states,
which only allow self-administration by patients with a diagnosis of terminal
illness, the proportion of deaths attributed to physician-assisted suicide remains
under 1% (Figure 1.2). The Panel notes that data collection and reporting
procedures vary substantially both within and among jurisdictions. Relevant
details and discussion of evidence from foreign jurisdictions are included in
the body of the reports.
5.0 Belgium
Canada
Luxembourg
4.0 Netherlands
Assisted Deaths (% of Total Deaths)
Switzerland
California
Oregon
3.0
Washington
2.0
1.0
0.0
1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
Year
Data Source: Belgium (CFCEE, 2004, 2006, 2008, 2010, 2012, 2014, 2016, 2018; SB, 2018);
Canada (GC, 2017b, 2017c, 2018b; StatCan, 2018c); Luxembourg (CNCE, 2017; Gov. of Luxembourg, 2018);
Netherlands (RTE, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012b, 2013, 2014a, 2015d, 2016c, 2017d;
CBS, 2018; RTE, 2018b); Switzerland (Gov. of Switzerland, 2018b, 2018a); California (Gov. of CA, 2017, 2018);
Oregon (Gov. of OR, 2018a, 2018b); Washington: (Gov. of WA, 2018b, 2018c)
Figure 1.2
Reported Assisted Deaths as a Percentage of Total Deaths per Year by Location
Not all locations where some form of assisted dying is permitted publicly report the number of such
deaths each year; data presented in the figure are the best available at this time. Note that assisted
dying practices vary among U.S. states; data from individual states are presented where available.
1.5.4 Knowledge Gaps

Direct evidence on the practice of assisted dying in the three topic areas
is limited to publicly available documentation from the few countries that
allow assisted dying for mature minors, through advance requests, or where a
mental disorder is the sole underlying medical condition. However, many of
the questions and issues related to the three topic areas identified by the Panel
do have an evidence base, often spanning multiple disciplines including law,
ethics, medicine, nursing, psychology, psychiatry, and sociology. This evidence
forms the core of what the Panel assessed. There are nonetheless knowledge
gaps for these issues; where they exist, the Panel identified and factored them
into its findings.
1 . 6 HO W TO R E A D T H I S R E P ORT
This report is one of three related reports that collectively examine the evidence
related to medical assistance in dying: MAID for Mature Minors, Advance
Requests for MAID, and MAID Where a Mental Disorder Is the Sole Underlying
Medical Condition. Though each report is authored by a different Working
Group of the Expert Panel, the three reports have been developed in parallel
and benefitted from common discussions across the Working Groups.
These reports can therefore be read independently or as a single body of work.

To support this structure the three topic area reports share the same first two
chapters: Chapter 1: Introduction and Chapter 2: MAID in Canada: Historical and
Current Considerations. These two chapters provide common information and
context relevant to all three reports. The chapters that follow comprise the
core of the topic area assessment. Chapters 3 through 5 present context, issues,
and evidence specific to the respective topic area. Chapter 6 is a discussion of
potential impacts, implications, and safeguards. Each report concludes with
its own Chapter 7, which provides summary answers to the charge.
Chapter 2 MAID in Canada: Historical and Current Considerations 13
2
MAID in Canada: Historical and
Current Considerations
• How Did We Get Here?
• Implementation of MAID in Canada
• Provision of Healthcare in Canada
• Healthcare Decision-Making
• Chapter Summary
2 MAID in Canada: Historical and

Current Considerations
The partial decriminalization of MAID in Canada followed a succession of

legal challenges, societal and technological changes, advocacy and scholarly
work, and public and professional discussions, some of which began more
than 50 years ago. The Panel understands that MAID is a deeply personal topic
about which there are differing views on the relevant evidence, and that one’s
perception about the need for the practice to include mature minors, advance
requests, or where a mental disorder is the sole underlying medical condition
is informed by life experiences, values, and beliefs. Moreover, Panel members,
regardless of their own disciplinary expertise, recognize that clinical, ethical,
legal, and societal considerations may be in tension with one another. This
chapter provides a context for current discussions of MAID in Canada with the
understanding that these discussions will continue to evolve.
The chapter begins with an overview of some pivotal points in this history,
along with certain contemporary realities of delivering healthcare services
in a culturally diverse and geographically expansive country. The three topic
areas also touch on several common considerations — informed consent,
decision-making capacity, and decision-making authority — each of which is
discussed in the context of MAID in Canada. Given the breadth and complexity
of issues, the chapter seeks to provide the reader with a common starting point
for thinking about MAID in the three topic areas. It does not purport to be a
definitive or comprehensive examination of the historical, social, and political
context of MAID in Canada.
2 . 1 HO W D I D WE GE T H E RE ?
The public conversation in Canada about end-of-life decision-making dates back

more than half a century. The development of new life-prolonging technology
and medical interventions prompted conversations about their use and/or
withdrawal among patients, families, clinicians, and institutions. Arnup (2018),
citing Smith and Nickel (2003), points out that healthcare in Canada in the
post-war years featured new technologies and focused on saving lives, and
that “little thought was given to dignity, pain relief or quality of care” of the
dying. By the late 1960s, however, the palliative care and hospice movements
began to take hold, based on the idea that patients at the end of life required
equal clinical attention — albeit of a different kind — even when cure was
no longer possible (Mount, 1976; Saunders, 2001; Arnup, 2018). High-profile
cases, such as that of Karen Ann Quinlan in the United States, brought public
attention to end-of-life discussions about cessation of treatment and quality
of life (Martin, 2016).
In 1982, the Law Reform Commission of Canada published a working paper,

followed in 1983 by a full report, entitled Euthanasia, Aiding Suicide and Cessation
of Treatment (LRCC, 1982, 1983). The Commission recommended against
decriminalization or legalization of euthanasia or assisted suicide, but did make
recommendations to clarify the legal right of a patient to refuse treatment and
of a physician to cease treatment that has become therapeutically useless and
is not in the best interests of the patient (LRCC, 1983). Nine years later, the
decision in the case of Nancy B. in Quebec City affirmed a capable patient’s
right to refuse life-sustaining treatment even if such a decision led to death
(QCCS, 1992).
2.1.1 Sue Rodriguez Challenges the Assisted Suicide

Prohibition in Canada
In the early 1990s, Sue Rodriguez, a woman with amyotrophic lateral sclerosis
(ALS), applied to the Supreme Court of British Columbia to have the Criminal
Code prohibition on assisted suicide declared unconstitutional. After the British
Columbia Supreme Court dismissed her application, Ms. Rodriguez appealed
to the British Columbia Court of Appeal and, after being unsuccessful there, to
the Supreme Court of Canada (SCC, 1993).
The key constitutional rights implicated by the prohibition on assisted suicide

were Sections 7 and 15(1) of the Canadian Charter of Rights and Freedoms (GC,
1982). Section 7 states that everyone has “the right to life, liberty and security
of the person and the right not to be deprived thereof except in accordance
with the principles of fundamental justice.” Section 15(1) states that every
person has the right to “equal protection and equal benefit of the law without
discrimination and, in particular, without discrimination based on race, national
or ethnic origin, colour, religion, sex, age or mental or physical disability.”
While actions taken by governments are subject to these provisions, Section 1 of
the Charter states they may limit rights insofar as such limits are “reasonable,”
“prescribed by law,” and “demonstrably justified in a free and democratic
society.” Ms. Rodriguez argued that she would be unable to take her own life
without assistance when she no longer had the capacity to enjoy life because of
her disease. Ms. Rodriguez stated that, since suicide is legal under the Criminal
Code, prohibiting assisted suicide discriminates against people with a physical
disability that makes them incapable of taking their own life (SCC, 1993).
On September 30, 1993, the Supreme Court of Canada ruled, by a five-to-four

majority, that the prohibition against assisted suicide was in accordance with the
principles of fundamental justice and as such did not violate Section 7 of the
Charter. The Supreme Court also concluded that a violation of Section 15(1) of
the Charter would be “demonstrably justified in a free and democratic society”
and ruled that the prohibition was constitutional (SCC, 1993).
2.1.2 Public Conversation, Consideration, and Study

Discussions of choice at end of life did not stop after the Rodriguez decision.
Following a series of papers published by the Canadian Medical Association
on assisted suicide and euthanasia in 1993, the Senate of Canada appointed
a Special Committee in 1994 to “examine and report on the legal, social and
ethical issues relating to euthanasia and assisted suicide” (SSCEAS, 1995).
The Committee heard testimony and reviewed letters and briefs from across
Canada for 14 months, before publishing a final report in 1995, with a majority
recommending against changing the legal status of euthanasia and assisted
suicide in Canada (SSCEAS, 1995).
Criminal cases reported in the media across Canada in the 1990s, such as those
of Robert Latimer in Saskatchewan and Dr. Maurice Généreux in Ontario,
inspired further public and private debate (see Deschamps, 2017a for a review
of cases). Moreover, Canadians were not insulated from highly publicized
international cases, such as those of Dr. Jack Kevorkian in the United States
(Martin, 2016). Advocacy groups, such as Dying with Dignity Canada and its
Quebec counterpart, Association québécoise pour le droit de mourir dans la
dignité, campaigned for choice at end of life in Canada. Within clinical practice,
discussions of appropriate end-of-life care practices and policy development
were ongoing (e.g., CFPC, 2012; CMA, 2014).
Academic study of the issues of euthanasia and assisted suicide by scholars

in Canada from a range of disciplines, including law, bioethics, philosophy,
and history, informed perspectives about the practice (e.g., Somerville, 2001;
Downie, 2004; Dowbiggin, 2005; Sumner, 2011). In 2011, the Royal Society of
Canada published a multidisciplinary review of end-of-life decision-making
that included research on assisted death (RSC, 2011).
In recent decades, legislative attempts to amend the Criminal Code to permit

euthanasia and/or assisted suicide in limited circumstances were unsuccessful.
These attempts came from diverse political parties: Svend Robinson (New
Democratic Party, 1992, 1994), Francine Lalonde (Bloc Québécois, 2005,
2008, 2009), Stephen Fletcher (Conservative Party, 2014), and Nancy Ruth
(Conservative Party, 2014) (Butler et al., 2013; Deschamps, 2017a).
2.1.3 Quebec Enacts End-of-Life Legislation that Includes

Medical Aid in Dying
In 2006, Quebec’s medical regulator, Collège des médecins du Québec (CMQ),
embarked on a three-year process to study appropriate care at the end of life
(CMQ, 2009). In November 2009, a working group report concluded that,
despite advances in palliative care, there were exceptional cases in which clinical
interventions were ineffective and, in those situations, a patient would have no

option but to suffer until death (CMQ, 2009); this position was subsequently
adopted by the CMQ (Robert, 2010). In December 2009, the National Assembly
of Quebec unanimously adopted a motion to create a select committee of
members to study the issue of dying with dignity (Gov. of QC, 2012).
Reporting to the National Assembly in March 2012, the committee noted that

opinion had shifted in public polls in support of euthanasia and assisted suicide,
and among healthcare practitioners in surveys conducted by professional
associations (Gov. of QC, 2012). In June 2014, the Quebec government passed
An Act Respecting End-of-Life Care (Gov. of QC, 2014), which took effect in
December 2015. This Act addresses patients’ entitlement to receive the full
spectrum of care at the end of life, and includes medical aid in dying. The
Quebec eligibility criteria and safeguards are similar, but not identical, to those
of the federal statute (Gov. of QC, 2014).
2.1.4 Carter v. Canada Overturns the Blanket Prohibition on

Assisted Suicide
In 2011, two family members of Kay Carter (a woman with spinal stenosis
who had travelled to Switzerland for an assisted suicide), William Shoichet (a
medical doctor willing to participate in physician-assisted deaths), and Gloria
Taylor (a woman with ALS) joined with the British Columbia Civil Liberties
Association to challenge federal prohibition on physician-assisted dying. In
2015, the Supreme Court of Canada concluded that the challenged provisions
of the Criminal Code were void insofar as:
[T]hey prohibit physician-assisted death for a competent adult person

who (1) clearly consents to the termination of life and (2) has a grievous
and irremediable medical condition (including an illness, disease or
disability) that causes enduring suffering that is intolerable to the
individual in the circumstances of his or her condition.
(SCC, 2015)
In contrast to the five-to-four decision in Rodriguez v. Canada (1993), the Carter

decision was unanimous (9-0); the decision stated that a blanket prohibition
on assisted suicide deprives adults of the right to life, liberty, and security of
the person. For the purposes of the reports, it is important to note that Carter
considered the case of adults with decision-making capacity, and that it made
“no pronouncement on other situations where physician-assisted dying may
be sought” (SCC, 2015). The Supreme Court confirmed at the same time the
role of the criminal law, suspending the declaration of invalidity of the criminal
prohibition for one year to allow time for a legislative and regulatory response
to the judgment (SCC, 2015).
2.1.5 Bill C-14 and the Partial Decriminalization of MAID

In response to the Carter ruling, after study and consultation (e.g., PTEAG,
2015; SJCPAD, 2016), the federal government introduced Bill C-14, An Act to
Amend the Criminal Code and to Make Related Amendments to Other Acts (Medical
Assistance in Dying). The Act received Royal Assent on June 17, 2016, creating
the federal statutory framework for MAID (GC, 2016b).
The preamble to the federal MAID legislation takes into consideration the
autonomy and intolerable suffering of persons with grievous and irremediable
medical conditions who wish to seek MAID; the need for “robust safeguards …
to protect against errors and abuse;” affirmation of the “inherent and equal
value of every person’s life” and the avoidance of “negative perceptions of the
quality of life of persons who are elderly, ill, or disabled;” the protection of
vulnerable persons from “being induced, in moments of weakness, to end their
lives;” and the recognition that “suicide is a significant public health issue that
can have lasting and harmful effects on individuals, families and communities”
(GC, 2016b). The preamble concludes:
permitting access to medical assistance in dying for competent adults

whose deaths are reasonably foreseeable strikes the most appropriate
balance between the autonomy of persons who seek medical assistance
in dying, on one hand, and the interests of vulnerable persons in need
of protection and those of society, on the other.
A specific concern of the legislators, as evidenced in the preamble to the Act,

was a possible impact of MAID on suicide rates and suicide prevention. Suicide
is not a criminal offence in Canada, but assisting a person to end their life is
illegal unless the conditions of the MAID legislation are met (GC, 2016b). In
addition to being a public health issue, suicide prevention is also foundational
to the practice of mental health services. Suicide, suicide prevention, and the
possible impacts of MAID laws are discussed in detail in Sections 3.2 and 4.2.
The legislation provides eligibility criteria and procedural safeguards to establish

the parameters of legally permissible MAID in Canada (Box 2.1).
Box 2.1
Eligibility Criteria for Accessing MAID in Canada
241.2 (1) A person may receive medical assistance in dying only if they meet all of
the following criteria:
(a) they are eligible — or, but for any applicable minimum period of residence or
waiting period, would be eligible — for health services funded by a government
in Canada;
(b) they are at least 18 years of age and capable of making decisions with respect
to their health;
(c) they have a grievous and irremediable medical condition;
(d) they have made a voluntary request for medical assistance in dying that, in
particular, was not made as a result of external pressure; and
(e) they give informed consent to receive medical assistance in dying after having
been informed of the means that are available to relieve their suffering, including
palliative care.
241.2 (2) A person has a grievous and irremediable medical condition only if they
meet all of the following criteria:
(a) they have a serious and incurable illness, disease or disability;
(b) they are in an advanced state of irreversible decline in capability;
(c) that illness, disease or disability or that state of decline causes them enduring
physical or psychological suffering that is intolerable to them and that cannot
be relieved under conditions that they consider acceptable; and
(d) their natural death has become reasonably foreseeable, taking into account all of
their medical circumstances, without a prognosis necessarily having been made
as to the specific length of time that they have remaining.
(GC, 2016b)
Two independent medical or nurse practitioners must be of the opinion that the
person requesting MAID meets all of the eligibility criteria. Furthermore, there
must be 10 clear days between the formal request and the provision of MAID,
unless the person’s death or loss of capacity is imminent. Immediately prior to
the provision of MAID, the person must be given an opportunity to withdraw
their request and must give express consent to the procedure (GC, 2016b).
Thus, mature minors under the age of 18 are not eligible for MAID; competent
persons cannot provide valid consent by means of an advance request for MAID;
and competent persons with a mental disorder as their sole underlying medical
condition will rarely meet all of the eligibility criteria.
2 . 2 I M P LE M E N TAT I ON OF M AI D I N CANADA
The best available data indicate that 3,714 people in Canada accessed MAID
between December 10, 2015 and December 31, 2017 (GC, 2018b). This number
includes data from Quebec (but only until June 9, 2017), and excludes data from
Yukon, Northwest Territories, and Nunavut. In 2017, MAID deaths represented
approximately 1% of all deaths in Canada (GC, 2018b).
The most common underlying conditions among those who received MAID in
2017 (n=1,961)1 were cancer (64%), followed by diseases of the circulatory/
respiratory system (17%), and neurodegenerative conditions (11%); 51% of
recipients were men and 49% women. People ranged in age from 18–45 to over
90 years old, with the largest demographic being 65–70 years of age (Figure 2.1).
New federal monitoring regulations, introduced July 25, 2018, specify reporting
requirements and designate a recipient to receive reports from medical and
nurse practitioners and pharmacists in each province and territory (GC, 2018a).
Prior to the introduction of federal monitoring regulations, Health Canada
produced three interim reports based on available data from the provinces
and territories (GC, 2017b, 2017c, 2018b).
1 Excludes data from Yukon, Northwest Territories, Nunavut, and Quebec.

Unknown
91+
86-90
81-85
76-80
Age Range
71-75
65-70
56-64
46-55
18-45
0 50 100 150 200 250 300 350

Number of Cases
Other 8%
Women 49%
Neurodegerative 11%
Men 51% Circulatory or

Respiratory
System 17%
Cancer-related 64%
Data Source: GC, 2018b
Figure 2.1
Characteristics of Reported MAID Deaths in Canada in 2017
MAID deaths in Canada, as reported to Health Canada in 2017, by age, gender, and underlying
medical condition. The figure excludes data from Yukon, Northwest Territories, Nunavut, and Quebec.
In Quebec, An Act Respecting End-of-Life Care legislated the creation of a commission

that submits an annual activity report, no later than September 30, to the
Minister of Health and Social Services (Gov. of QC, 2014). Since its inception,
the Commission has published two reports, the first in October 2016 (Gov. of
QC, 2016) and the second in October 2017 (Gov. of QC, 2017a). Additionally,
executive directors of health and social services institutions, as well as the CMQ
(which collects reports directly from individual private practice physicians),
are required to publicly report on numbers of MAID requests and outcomes
(GC, 2018b).
2.2.1 Pending Legal Challenges to MAID Legislation

The British Columbia Civil Liberties Association and Julia Lamb, a 25-year-old
woman with spinal muscular atrophy (a progressive degenerative condition),
filed a constitutional challenge to the federal Act on June 27, 2016 (BCCLA,
2016). The lawsuit challenges eligibility criteria (reasonably foreseeable death,
incurable illness or condition, advanced state of irreversible decline), arguing
that the federal legislation unjustifiably limits Sections 7 and 15 of the Charter
and is not saved by Section 1 (BCCLA, 2016).
In Quebec, in June 2017, Jean Truchon, a 49-year-old man with cerebral palsy,
and Nicole Gladu, a 71-year-old woman with post-polio syndrome, filed a legal
challenge against the assisted dying laws in Canada and Quebec (QCCS, 2017a).
They argue that the eligibility criteria in the legislation (“natural death has
become reasonably foreseeable” and “end of life”) are too restrictive, violate
Sections 7 and 15 of the Charter, and cannot be saved under Section 1.
Also in Quebec, Paul Saba, a physician, has variously challenged the validity
of the Quebec statute on assistance in dying and the federal MAID law on
several bases, including that the current deficiencies in healthcare services
prevent patients from giving informed consent. He also claims that the regime
is unconstitutional and goes against Quebec’s Code of Ethics of Physicians and
the Canada Health Act (QCCS, 2017b).
In a statement of claim filed with the Ontario Superior Court of Justice, Roger
Foley, who has a serious neurological disability, claims that the defendants (his
local hospital, local health integration network, and others) have violated his
Charter rights by failing to provide adequate and appropriate home care services
to relieve his suffering. Additionally, he claims the defendants have offered
to provide assisted suicide instead of an assisted life. He also seeks, in part, a
declaration that the MAID provisions in the Criminal Code are unconstitutional
and therefore invalid (ONSC, 2018).
2.2.2 Legal Interpretations of MAID Legislation

In 2017, the Ontario Superior Court of Justice made an interpretive declaration
regarding the eligibility criterion of a reasonably foreseeable death in the
discussion of a case involving a patient seeking MAID (AB v. Canada (Attorney
General)). Referring to the language used in Canada’s MAID legislation, the
Court stated:
This language reveals that natural death need not be imminent and
that what is a reasonably foreseeable death is a person-specific medical
question to be made without necessarily making, but not necessarily
precluding, a prognosis of the remaining lifespan.
(ONSC, 2017)
The College of Physicians and Surgeons of Nova Scotia has similarly provided
a broad interpretation of reasonable foreseeability in its Professional Standard
Regarding Medical Assistance in Dying, referencing the AB v. Canada (Attorney
General) case (CPSNS, 2018). Furthermore, an Inquiry Committee for the College
of Physicians and Surgeons of British Columbia found a woman had met MAID
eligibility criteria “despite the fact that her refusal of medical treatment, food,
and water undoubtedly hastened her death and contributed to its ‘reasonable
foreseeability’” (CPSBC, 2018).
The College of Physicians and Surgeons of Ontario has two policies requiring
physicians who conscientiously object to MAID to make an effective referral for
patients who request MAID (CPSO, 2015, 2016). Several groups and individual
physicians challenged these policies, stating they violate one’s right to freedom
of religion, freedom of conscience, and right to equality. The Ontario Superior
Court of Justice (Divisional Court) decided on January 31, 2018 that any
infringement on physicians’ freedom of religion was justified given its objective
of ensuring equitable access to healthcare (ONSCDC, 2018). An application
for leave to appeal was filed in the Ontario Court of Appeal on February 20,
2018 (Golding & Rosenbaum, 2018).
2.2.3 MAID Delivery and Regulation

MAID is an exemption in the Criminal Code to criminal offenses of homicide
and assisted suicide, as long as specific eligibility criteria are met and certain
safeguards are followed (Box 2.1). Debates about eligibility criteria for MAID
include debates about the scope of criminal law, the prohibitions on causing
death that the criminal law contains, and the social norms represented therein.
However, MAID is also a medical act, regulated and delivered through the
healthcare system, as, by law, only medical and nurse practitioners can provide
MAID in Canada. Thus, a brief overview of MAID delivery and regulation in
the healthcare system follows.
Provinces and territories are primarily responsible for delivering healthcare

services to their residents; however, the federal government has responsibility
in providing primary healthcare to certain groups (GC, 2012a). Provincial and
territorial healthcare legislation defines the obligations of health authorities,
healthcare institutions, and individual practitioners with respect to the delivery
of healthcare services. These obligations are set out in legislation regulating,
for example, hospitals (e.g., Gov. of NS, 1989) and healthcare consent (e.g.,
Gov. of ON, 1996). In the case of Quebec, provincial legislation regulates end-
of-life care, including MAID (Gov. of QC, 2014). Subsequent to the passage of
the federal MAID legislation, Manitoba and Ontario introduced or amended
statutes to address implementation (e.g., Gov. of MB, 2017; Gov. of ON, 2017).
Provincial and territorial legislation establishes regulatory colleges that enforce

standards of practice and regulate the conduct of professional healthcare
providers, such as nurses, physicians, and pharmacists. Colleges enforce standards
through the licensing and disciplining of professional members; their purpose
is to serve and protect the public, ensuring competency and quality of practice
within their professions (e.g., Gov. of BC, 1996a). Quebec has legislation
defining codes of ethics for specific professions, such as physicians (Gov. of
QC, 2017b). Many regulatory colleges have developed professional standards
and policies for the assessment and provision of MAID by their members (e.g.,
CPSO, 2016; CPSNS, 2018; CRNBC, 2018).
Hospitals also regulate the practices provided by their institutions and within
their facilities, including the provisioning of MAID. There may be public and
independent health facilities regulated by different pieces of legislation within
a province or territory (e.g., Gov. of ON, 1990a, 1990b, 1990c). Physicians, in
law, are generally treated as independent contractors; however, hospitals exert
control over the professional conduct of physicians, for instance, by granting or
revoking privileges to provide care in their facility. Hospitals hold the authority
to hire and regulate the conduct of other healthcare professionals, such as
nurses and pharmacists. Many hospitals have developed policies to regulate
the provision of MAID (e.g., TOH, 2016).
Professional associations and societies, such as the Canadian Association of

MAID Assessors and Providers (CAMAP), the Canadian Society of Palliative Care
Physicians (CSPCP), and the Canadian Nurses Association, are organizations
of healthcare practitioners and scholars. These organizations seek to provide
support, information, and guidance to healthcare practitioners, but do not
license members and do not have regulatory authority.
2.2.4 End-of-Life Practices Other than MAID

Though MAID is a novel practice in Canada, subject to eligibility and safeguards
prescribed by the Criminal Code, it is implemented in a healthcare context where
long-standing end-of-life practices exist, such as withdrawing or withholding
treatment, continuous palliative sedation therapy, and abstaining from nutrition
and hydration. This section briefly reviews their legal status in Canada.
Withdrawing or Withholding Life-Sustaining Treatment

Under Canadian law, people with decision-making capacity clearly have the right
to refuse treatment even where that refusal will result in their death (QCCS,
1992). There is no formal requirement in law that refusals be well considered
or settled. Mature minors and individuals with a mental disorder who have
decision-making capacity may choose to withdraw or withhold life-sustaining
treatment, as may their substitute decision makers (SDMs), should they later
lose decisional capacity.
Refusals of treatment can be expressed through an advance directive, which may

be in the form of written instructions or a chosen SDM. An SDM appointed by
operation of a statute (e.g., family member) may decide, on behalf of a patient
who lacks decision-making capacity, to withdraw or withhold life-sustaining
treatment if they believe it is in accordance with the patient’s wishes (where
known), or the best interests of the patient (where the patient’s prior capable
wishes are not known) (see Section 3.3.2 in The State of Knowledge on Advance
Requests for Medical Assistance in Dying.
Continuous Palliative Sedation Therapy (CPST)

The Canadian Medical Association defines CPST as “complete sedation, with
the intent of rendering the patient unable to experience the environment,
sensation or thoughts, until the patient dies naturally from the underlying
illness” (CMA, 2017). CPST is clearly legal when it does not cause death — that
is, when delivered in combination with cessation of artificial hydration and
nutrition where death is anticipated within approximately 48 hours (Downie,
2017). Where death is anticipated within two weeks, CPST with the provision
of artificial hydration and nutrition is clearly legal (again, it does not cause
death) (Downie, 2017). In practice, CPST is generally done without artificial
hydration and nutrition. Where death is anticipated within 14 days, the legal
status of CPST in combination with cessation of artificial hydration and nutrition
is less clear (Downie, 2017); however, it is arguably legal (Downie, 2018). Where
death is not anticipated for some time, the legal status of CPST in combination
with cessation of artificial hydration and nutrition is unclear.
Voluntary Stopping of Eating and Drinking (VSED)

Some patients choose to stop eating and drinking, knowing they will die as
a result. Competent patients can refuse oral hydration and nutrition (e.g.,
holding a glass to a person’s lips, spoon-feeding) and artificial hydration and
nutrition (e.g., intravenous fluids, feeding tube), and advance directives (where
applicable in Canada) may also include refusal of artificial hydration and
nutrition (Downie, 2017). In some provinces (e.g., Nova Scotia), oral hydration
and nutrition can also be refused through advance directives; however, this is
less clear in some other provinces (e.g., BCCA, 2015).
VSED has been used in Canada as a pathway to eligibility for MAID. If one stops
eating and drinking, their natural death becomes reasonably foreseeable (or,
in Quebec, the person reaches their “end of life”). For example, a Quebec man
refused food for 53 days and water for 8 days in order to become eligible for
MAID (McKenna, 2016). Similarly, a woman in British Columbia refused food and
water for 14 days in order to become eligible to receive MAID (CPSBC, 2018).
2 . 3 P R O VI S I O N OF H E ALT H CAR E I N CANADA
As a first point of contact, primary healthcare services offer immediate care

for health problems, routine care, or health information. Family physicians,
nurse practitioners, pharmacists, and telephone advice lines can provide these
kinds of services. Primary healthcare also provides coordination of specialized
services, such as specialist consultation and care (e.g., cardiologists, allergists,
psychiatrists) or care provided in hospitals (GC, 2012b).
In 2013, about 29% of people in Canada aged 15 or older reported difficulty

in accessing healthcare services, most commonly due to wait times or difficulty
securing appointments (Clarke, 2016). In 2016, 15.8% of those aged 12 or older
reported that they did not have a regular healthcare provider2 (StatCan, 2017b).
Men aged 18 to 34 were the most likely group to report not having a regular
healthcare provider (approximately 33%), whereas men and women over the
age of 65 were the least likely group (6.5% of men and 5.3% of women). Self-
identified Indigenous people were more likely to report not having a primary
healthcare provider (19.2%) compared to the rest of the population (15.8%)
(StatCan, 2017b). Large geographic distances among communities and low
population densities make healthcare more costly in remote areas, resulting
in reduced access to services and professionals; this is most pronounced in
northern parts of Canada, where visiting professionals or locums provide many
2 Estimates exclude the territories, because the survey did not cover all communities in 2016.
key health services periodically on a short-term basis (NCCAH, 2010). To receive

specialized care, patients are often required to leave their home communities
by flying to more densely populated centres (NCCAH, 2010; MacIntosh, 2017).
With respect to end of life, access to palliative care also varies across Canada.
Access to palliative care and coverage of services such as pharmaceuticals,
home care, psychologists, and residential long-term care exist piecemeal across
provinces and territories, and are funded through a mix of public programs,
private insurance, and out-of-pocket payments by individuals (Carstairs, 2010;
Chappell & Hollander, 2011; Verma et al., 2014). Gaps in existing data present
challenges in understanding the full extent of this issue (Canadian Cancer
Society, 2016). An oft-cited statistic notes that only 16 to 30% of people in
Canada have access to palliative care (Carstairs, 2010), though it is based on a
study of in-hospital palliative care in Western Canada only (Downie & Lloyd-
Smith, 2014). Barriers to access include issues of training and education among
healthcare professionals, such as the lack of adequate training in palliative
care in Canada (Stonebridge, 2017). In a letter to the Quebec Health Minister
dated May 29, 2018, the CMQ raised concerns that, because palliative care and
social services are increasingly diverted to those who make a request for MAID,
patients may seek to access these services by requesting MAID (CMQ, 2018).
2.3.1 Health and Health Equity in Canada

There are significant disparities in health in Canada. For example, life expectancy
is consistently lower than average in regions with high unemployment rates,
lower educational achievement, and greater material and social deprivation
(PHAC, 2018). Low socio-economic status is also related to higher incidences of
chronic disease, such as arthritis, asthma, and diabetes (PHAC, 2018). Studies
have demonstrated that immigrant, racialized, and ethnocultural groups face
barriers in accessing physical and mental healthcare (McKenzie et al., 2016).
Disparities in preventive care such as reduced access to breast cancer screening
or mental healthcare, as well as outcomes of care such as lower cancer survival
rates, have been reported (Booth et al., 2010; Kumachev et al., 2016; McKenzie
et al., 2016).
Such systemic factors (or social determinants of health) are estimated to

influence up to 60% of a population’s health status (CMA, n.d.). Healthcare
access can explain up to 25% of a population’s health status, while biology and
genetics account for 15% (CMA, n.d.). Social determinants of health include
community, housing, food security, physical environment, gender, ability, race,
and Indigenous status, among others (PHAC, 2018).
Social determinants can affect the risk of developing an illness, the course and
severity of the illness, and the availability of treatment. Stigma and discrimination
influence health outcomes, affecting some groups and individuals differently.
People with disabilities and their families have reported, for many years, that
the healthcare system makes negative assumptions about the quality of their
lives (e.g., Stainton & Besser, 1998; Gill, 2000; Drainoni et al., 2006); some
health professionals believe life with extensive disabilities is not worth living
(Gill, 2000). The need for improved health equity is a fundamental issue
in Canada, increasingly enshrined in provincial and territorial legislation.
Improving health equity allows people to achieve their full health potential
by removing preventable and avoidable systemic conditions that constrain life
choices, including choices at the end of life (e.g., Batavia, 2001).
2.3.2 Barriers to Healthcare for Indigenous People

Reconciliation with Indigenous people calls for the provision of services consistent
with their cultures and needs. Yet, formal healthcare for Indigenous people in
Canada has historically been highly segregated and of low quality (FNHA, 2017;
Geddes, 2017). The sharing of responsibilities among federal, provincial, and
territorial governments has created a patchwork healthcare system. Payment
disputes between federal and provincial/territorial governments can result in
delayed access to necessary health services (NCCAH, 2010).
Healthcare inequities experienced by Indigenous people have been well

documented (e.g., Loppie et al., 2014; Allan & Smylie, 2015; Hart & Lavallee,
2015; TRC, 2015a). Racism continues to create and reinforce disparities (Loppie
et al., 2014; Allan & Smylie, 2015), and, as noted in Section 2.3.1, inequitable
access to healthcare leads to poor health outcomes (Reading & Wien, 2009).
A lack of appropriate and safe healthcare can prevent Indigenous people
from seeking treatment (NCCAH, 2010); deficiencies in cultural safety and
competence, as well as historical and current abuses, have resulted in some
Indigenous people losing trust in the healthcare system (Geddes, 2017). Indeed,
the Truth and Reconciliation Commission called for the Canadian healthcare
system to recognize the value of Indigenous healing practices and use them
when treating Indigenous patients (TRC, 2015a).
Indigenous Peoples hold a variety of spiritual views that may inform conceptions
of health, death, and dying that are both different from and similar to Western
conceptions. Traditional teachings stress the interconnectedness of all of
creation, and that humankind is to live in harmony with the natural world
(NFB, 2015). In contrast to the positivist (i.e., empirical data-focused) attitudes
that dominate modern Western medicine, Indigenous conceptions of health
are more holistic in nature (Stewart & Marshall, 2017). For many Indigenous
people, connections to family, friends, community, nature, and culture are an
important part of the healing process, suggesting that they may be more receptive
to healthcare services based on a theme of interconnectedness (McCormick,
1997). The medicine wheel, for instance, underscores the importance of
balance and emphasizes four interrelated forms of health: physical, emotional,
spiritual, and mental/intellectual (Dyck, 1996). Some conceptualizations of
the medicine wheel also represent the four stages of life in the physical world:
birth, youth, adulthood, and death (NLM, n.d.). Many Indigenous people
believe in an afterlife and some view the dying process as preparation for the
afterlife journey (Kelly & Minty, 2007).
The Indigenous Elders who shared their knowledge and experiences at the
Elders Circle (Section 1.5.2) stated that life is sacred and, therefore, death
should not be the subject of casual discussion, which risks diminishing life’s
value. Ideally, individuals make end-of-life decisions as part of a community,
embedded in supportive relationships. The Elders felt that allowing MAID for
people with mental disorders could be damaging in communities experiencing
youth suicide crises. Elders also shared experiences of systemic barriers that
prevented them or their loved ones from accurate diagnoses and appropriate
treatment. Without basic access to appropriate healthcare and social services in
the community, the Elders expressed concern that MAID is a highly inappropriate
care option. Consideration of MAID in the three topic areas is a low priority for
most Indigenous communities that are also dealing with a lack of clean water,
food security, healthcare, and other basic needs. The Elders, while appreciative
of the CCA’s effort in facilitating the Elders Circle, noted that they do not speak
for all Indigenous perspectives. The Panel recognizes that too little input from
Indigenous people creates a significant gap in the evidence considered for
these reports. It is important to consider the potential needs and concerns of
Indigenous Peoples with respect to MAID in the three topic areas.
2.3.3 Culture and End-of-Life Care

Family, ethnicity, religion, workplace, education, as well as other factors contribute
to one’s cultural experience. Culture can be profoundly influential in how
people, both patients and healthcare practitioners, view end-of-life medical
care, and death and dying in general (Chakraborty et al., 2017). As a result,
one’s choice in medical treatment is likely affected by one’s personal views on
death. While discussions on medical options to prolong life may be appropriate
and desirable for some, others may view them as an interference in the natural
passage of life (Coolen, 2012). In some cultural traditions, suffering is an essential
and spiritually meaningful part of life, and something to be experienced and
endured rather than avoided (Searight & Gafford, 2005). Lived experience
of racism and historical trauma in the healthcare system also play a role in
attitudes towards end-of-life care (e.g., Welch et al., 2005).
Religion and spirituality can be especially important when making end-of-life

medical decisions (Chakraborty et al., 2017). Religion may play an essential
role in providing meaning and insights into issues of health, medicine, death,
dying, and philosophies about an afterlife (O’Connell, 1995). There are
diverse perspectives among and even within the faith traditions, which are
not homogenous (e.g., orthodox or conservative versus reform or liberal
perspectives). This diversity of perspective shapes the opinions that religious
people may have about MAID.
The diversity of cultural experiences in Canada influences any examination

of the impacts and implications of MAID in the three topic areas. A thorough
consideration of these perspectives was beyond the scope of the reports and
remains a significant knowledge gap.
2 . 4 HE A LTHC A R E DE CI S I ON-M AK I NG
In Canadian law, respect for a person’s autonomy and the protection of their
bodily integrity are the core values underlying the principle that decisions
made by capable individuals must be respected, and the more specific rule
that consent must be obtained prior to treatment (Gilmour, 2017). There are
exceptions to this general rule: for example, in some provinces and territories,
refusals made by capable minors (Day, 2007) or by capable adults who are
involuntarily committed to hospital because of mental disorders may not be
followed (Wildeman, 2016). Discussions of healthcare decision-making occur
more specifically in each topic area report, but three decision-making concepts
are important to clarify for consistency: informed consent, decision-making
capacity (as a clinical and legal concept), and decision-making authority.
2.4.1 Informed Consent

Provincial and territorial legislation specifies that informed consent must be:
• related to the proposed healthcare;
• given voluntarily;
• not obtained by fraud or misrepresentation;
• given by a person capable of making the healthcare decision;
• given by a person who has had the opportunity to ask questions about the
proposed care and alternatives, and receive answers; and
• given by a person adequately informed to understand the proposed care,
including information on the nature of the proposed care, its risks and
benefits, and on reasonable alternatives to the proposed care, including
non-treatment.
(Gov. of BC, 1996c; Gov. of ON, 1996;
Gov. of PE, 1988; Gov. of YK, 2003a)
Nova Scotia requires hospitals to obtain informed consent to care for patients;
however, this statute does not extend to facilities other than hospitals (Gov. of
NS, 1989). Quebec requires physicians to obtain informed consent from patients
as stated in the Code of Ethics of Physicians (Gov. of QC, 2017b) and established
in the Civil Code of Quebec (Gov. of QC, 1991). Outside Quebec, common law
determines informed consent requirements for provinces and territories that
do not have explicit legislation and for practices that are outside the scope of
legislation on healthcare consent (Wahl et al., 2014).
2.4.2 Decision-Making Capacity

All adults are presumed to have decision-making capacity unless there are
reasonable grounds to believe otherwise or unless legislation removes that
presumption (Gilmour, 2017). A patient has capacity when they have the
ability to understand and appreciate the nature and consequences of their
decisions. Capacity refers to the cognitive abilities necessary for sound decision-
making — specifically, being able to understand information relevant to making
a decision and the ability to appreciate the reasonably foreseeable consequences
of a decision (or lack of decision). When questioned, capacity becomes decision-
and time-specific; it is assessed in relation to the decision to be made and at the
time of its implementation. It is not a global determination of the presence or
absence of a person’s overall decision-making ability (Gilmour, 2017).
Guidelines, policies, and guidance related to capacity and consent are provided
by health regulatory colleges, and in some cases by employers (e.g., hospitals,
health authorities), experts, scholars, and organizations such as the Canadian
Medical Protective Association (CMPA) (LCO, 2017; CMPA, n.d.). There is no
universally accepted clinical approach to capacity assessment (Seyfried et al.,
2013) and little data on the assessment of capacity in the specific circumstances
of MAID (i.e., in the presence of intolerable suffering) (Cartagena et al., 2016).
In determining capacity for clinical decisions, healthcare practitioners typically
use either a directed clinical interview or a formal capacity assessment tool
such as the MacArthur Competence Assessment Tool (MacCAT) (Grisso et
al., 1997) or Aid to Capacity Evaluation (ACE) (Etchells et al., 1999).3 Formal
capacity assessment tools remind clinicians what dimensions of understanding
and appreciation to question; it is then up to the clinician to judge whether a
person’s abilities fulfil (or not) the criteria laid out in law or policy.
Clinicians determine when a capacity assessment is appropriate (Leo, 1999;

Ganzini et al., 2004; Dastidar & Odden, 2011), unless a court has already
determined a person is legally incompetent or the person is deemed to lack
capacity by the operation of a statute. The purpose of a clinical capacity
3 For a comprehensive list of clinical capacity assessment tools, see Kim (2010).
assessment is to provide a yes/no judgment about whether a specific person

can consent to a specific medical treatment (at a specific time, in a specific
context) (Charland, 2015).
2.4.3 Decision-Making Authority

Adults with decision-making capacity have legal authority over their healthcare
decisions. However, the decision-making authority of minors and involuntarily
committed patients, regardless of capacity, is constrained in some provinces and
territories (more details can be found in this report and the report The State of
Knowledge on Medical Assistance in Dying for Mature Minors). If an adult is found
to lack decision-making capacity, the healthcare practitioner must notify and
explain this finding to the individual. The next step is to determine whether
there is a valid instruction directive, applicable to the medical decision at hand.
The healthcare practitioner must identify (or determine) who the SDM is. That
may be someone identified by the patient in a written document prior to losing
capacity (i.e., a proxy directive) (Dalhousie Health Law Institute, 2017). The
SDM may also be a guardian or person appointed by a statute or court. Some
provinces and territories have recognized alternative models to substitute
decision-making in limited circumstances, such as supported decision-making
(e.g., Gov. of BC, 1996b; Gov. of YK, 2003b; Gov. of AB, 2008; Gov. of MB, 1993)
and co-decision-making (Gov. of SK, 2000).
If there is no recognized, appointed SDM, most provincial and territorial

legislation defines a nearest relative who can act on behalf of the person for the
specific treatment decision at hand (e.g., Gov. of BC, 1996c; Gov. of SK, 2015).
SDMs act in accordance with the person’s prior capable wishes; if unknown,
the SDM makes a decision in the person’s best interests. For more information
on advance directives, see Section 3.3.2 of The State of Knowledge on Advance
Requests for Medical Assistance in Dying.
2 . 5 C HA P TE R S U M M ARY
Recent changes in Canadian law have led to the partial decriminalization of

MAID. Informed discussions of MAID must consider the complex legislative and
regulatory Canadian contexts outlined above, as well as the broader historical
context that informs a diversity of perspectives on how best to approach MAID
with respect to the three topic areas. The relative significance of healthcare and
specialized services regulation, delivery, and access, however, varies across the
three topic areas, and considerations of informed consent, decision-making
capacity, and decision-making authority will particularly diverge. Indeed, as
presented in these reports, MAID as it relates to mature minors, advance
requests, and where a mental disorder is the sole underlying medical condition
gives rise to distinct issues that interface differently with the various aspects of
Canada’s healthcare and legal systems.
Chapter 3 Mental Disorders in Canada 33
3
Mental Disorders in Canada
• The Concept of Mental Disorder
• Suicide
• Prevalence and Socio-Economic/Demographic

Correlates of Mental Disorders, and Access to
Care in Canada
• Indigenous People and Mental Health
• Other Specific Populations and Mental Health
• Legal Landscape for Mental Health and MAID
• Knowledge Gaps
3 Mental Disorders in Canada
Key Findings
In Canada, all adults — including those with mental disorders — are presumed to
have the legal capacity to make medical decisions. The presumption of capacity can be
overridden in cases where a formal capacity assessment by a healthcare practitioner
indicates that a person lacks decision-making capacity (Section 3.6.2).
There is a long history of stigma, discrimination, and paternalism against people with
mental disorders in Canada and elsewhere. The lives of those with mental disorders
have been valued less than the lives of those without mental disorders. Freedoms
and choices have been unjustly restricted (Section 3.3.3).
Most mental disorders lack the prognostic predictability of the physical conditions
that currently motivate MAID requests in Canada. There is less certainty about how a
person’s mental disorder will evolve over time and whether treatments and/or social
interventions will be effective in relieving their suffering and improving their quality
of life. However, predictability can be higher for certain conditions, or for patients
who have undergone multiple treatments over a longer period of time (Section 3.1.2).
Having a mental disorder is one of the strongest risk factors for suicide (Section 3.2.1).
A range of policies and laws in Canada demonstrate society’s commitment to suicide

prevention. Research demonstrates that most people who attempt suicide are
ambivalent about wanting to die (Section 3.2.1).
Although mental disorders can affect anyone, having a mental disorder is strongly
correlated with certain social, economic, and environmental inequalities, such as
poverty, unemployment, homelessness, social isolation, stigma, and discrimination.
Further, people with mental disorders face impediments to accessing appropriate
mental healthcare in Canada (Section 3.3.2).
Provinces and territories have enacted mental health laws and policies acknowledging
that differential treatment of those with mental disorders is acceptable in certain
specific situations due to characteristics of the mental disorder (Section 3.6.3).
The evidence examined in this report has been gathered to help inform policy-
makers about the potential implications of permitting or prohibiting medical
assistance in dying in cases where a mental disorder is the sole underlying
medical condition (such cases are hereafter referred to in this report as MAID
MD-SUMC). The phrase “sole underlying medical condition” originated in
Bill C-14 and is provided in the charge (Section 1.1); it serves to differentiate
between cases in which a person with a mental disorder already meets MAID
eligibility criteria due to a physical condition from those cases in which a mental
disorder is the only illness, disease, or disability that motivates a MAID request.
As noted in the charge, this report does not examine cases in which a person
with a mental disorder as their sole underlying medical condition qualifies for
MAID under the existing eligibility criteria.
The report uses the language of prohibiting and permitting more (or expanding)
MAID MD-SUMC. The term prohibiting refers to the status quo in Canadian
law and to restricting MAID MD-SUMC further. The phrase permitting more
acknowledges that the current law allows MAID MD-SUMC, provided a person
meets all of the eligibility criteria.
Under current Canadian federal law and Quebec law, people whose mental
disorder is their sole underlying medical condition are not excluded from
MAID eligibility. The Expert Panel Working Group (hereafter Working Group)
identified one report of a person in Canada (“E.F.”) who received MAID when
a mental disorder seemed to be their sole underlying medical condition (E.F.
had conversion disorder, properly known as functional neurological symptom
disorder) (ABCA, 2016). The request was made and carried out in early 2016,
after the Carter ruling but before Bill C-14 came into force, and was granted by
the Alberta Court of Appeal under the Supreme Court of Canada’s decision
on constitutional exemptions to the ban on MAID. However, it is usually
difficult for someone with a mental disorder as their sole underlying medical
condition to meet the eligibility criteria set out in Bill C-14 due to the nature
of those disorders (see Section 4.1 for a detailed discussion of issues relating
to mental disorders and current MAID eligibility criteria).
The Working Group that produced this report was composed of experts from
a range of different disciplines, from different backgrounds, and with different
experiences. Each of these experts brought unique views and perspectives to
bear on the issue of prohibiting or permitting more MAID MD-SUMC. All of
these perspectives have informed and influenced the final report, which is
unlike the report that any single Working Group member would have produced
on their own. Nevertheless, it is the view of the Working Group that this report
can ultimately serve to help inform policy-makers about the issues and evidence
related to prohibiting or permitting more MAID MD-SUMC in Canada.
Given this wide range of perspectives and the controversial nature of the topic,
Working Group members do not agree on some fundamental issues. These
issues include the weighing of different outcomes resulting from prohibiting
or permitting more MAID MD-SUMC, the ethical and practical significance
of the reasonable foreseeability of a person’s death in the context of MAID,
the distinction (or lack thereof) between suicide and MAID MD-SUMC, the
impact of permitting more MAID MD-SUMC on current suicide prevention
strategies, and the distinction (or lack thereof) between MAID and other highly
consequential decisions that may result in a person’s death (e.g., refusing
life-sustaining treatment). In many areas, the Working Group did not reach
consensus on the interpretation and/or significance of the evidence, or about
what constituted relevant evidence. These disagreements are indicated in the
text, and are summarized in Box 7.1.
3 . 1 THE C O N C E P T OF M E NTAL DI S OR DE R
The field of psychiatry has found it challenging to determine which conditions

ought to be considered mental disorders (Murphy, 2017; Perring, 2018). Because
of this, the Working Group chose to rely on the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), a standard psychiatric diagnostic
classification scheme used in Canada.4 The DSM-5, published by the American
Psychiatric Association, serves various purposes beyond providing clinicians with
diagnostic criteria for mental disorders. It is also used for statistical, judicial, and
reimbursement purposes. In other words, it provides an exhaustive inventory
of conditions that may be of importance in diverse, non-clinical settings. As a
result, this expansive compendium may include conditions that psychiatrists
do not routinely treat, and which those affected do not consider to be mental
disorders, such as intellectual disabilities. Nevertheless, in this report, the term
mental disorders includes this full range of conditions. Although narrowing the
term’s definition to correspond to medical practice patterns and/or patients’
self-identification may be possible, the Working Group considered this task to
be beyond the scope of its charge.
4 Although the World Health Organization’s International Statistical Classification of Diseases and
Related Health Problems (ICD-10) is Canada’s official classification system, the DSM system is
widely used by many Canadian mental healthcare practitioners. The DSM is the most widely
used classification scheme in North America, while the ICD-10 is the most widely used system
in most of the rest of the world (Goldner et al., 2016).
3.1.1 Defining Mental Disorders

Mental disorders can be defined as health problems that disturb or impair a
person’s thoughts, experiences, emotions, behaviour, and/or ability to relate
to others (GC, 2002; APA, 2015; PHAC, 2015b). This broad definition includes
hundreds of conditions with diverse clinical profiles. While the focus of this
report is on mental disorders as a single category, it is important to note that
generalizations cannot be made about this category just as they cannot be made
about physical disorders as one group. Mental disorders may be characterized
by a relapsing and remitting course (as is often the case in bipolar disorder),
a stable course (as is usually the case for intellectual disabilities), a course of
progressive decline (e.g., most dementias),5 or an unpredictable course (e.g.,
addictions) (APA, 2013). Certain conditions (e.g., schizophrenia) may impact
a person’s ability to function personally or professionally, while many people
with other conditions (e.g., anxiety disorders) function well, to the extent that
their mental disorder does not significantly impact their life.
The threshold at which an experience or behaviour becomes pathological is

often determined not only by biological and psychological factors, but also by
social factors and cultural norms. In short, the identification, classification,
and diagnosis of mental disorders are not exclusively scientific, objective, and
value-neutral; rather, some normative, subjective, or value-laden sociocultural
conception of what counts as normal often frames society’s and clinicians’
perceptions of mental health and mental disorders (Perring, 2018).
The debate about the removal of the so-called “bereavement exclusion” from
the DSM-5 (Zachar, 2015; Zachar et al., 2017) illustrates this point. Until the
fifth edition of the DSM (2013), a person could not be diagnosed with major
depressive disorder within two months of the death of a loved one, even if
their experience of bereavement was indistinguishable from the symptoms of
major depression.6 This was not the case for other troubling life events such as
divorce or the onset of serious disease, which could lead to a diagnosis of major
depressive disorder in those who fulfilled depressive criteria following these
events. The bereavement exclusion was therefore removed from the DSM-5,
on the grounds that many difficult life events can trigger depressive episodes
and sometimes lead to recurrent depression, and that all such episodes are
equally pathological with respect to long-term outcomes. Those who opposed
5 Dementia is treated in greater detail in The State of Knowledge on Advance Requests for Medical
Assistance in Dying
6 Except in certain clinical circumstances, such as when the patient’s symptoms are “characterized
by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation” (APA, 1994).
the removal of the bereavement exclusion argued that intense grief following
the death of a loved one is a normal and appropriate human experience,
which should not be pathologized (Wakefield, 2011; Wakefield & First, 2012).
Supporters of the removal argued that, in cases where a person’s bereavement
fulfilled the DSM criteria for major depression, diagnosis and prognosis were
similar to cases brought on by other negative life events (Lamb et al., 2010;
Zisook et al., 2012). Importantly in this debate, both points of view consider the
same set of clinical circumstances, yet arrive at different judgments about whether
a certain experience is pathological or not.
Complicating matters further is the fact that, like many other mental disorders,
grief is (at least in part) culturally defined, which makes it difficult to apply strict
diagnostic criteria across multiple cultural settings. For example, according
to the DSM-5, complicated grief disorder can be diagnosed if a person is
grieving for more than six months (APA, 2015). However, different cultural
groups have different customs around grieving that do not correspond to the
DSM-5’s criteria. For example, some Indigenous Peoples have a traditional
grieving period of one year (HC et al., 2000).
3.1.2 Diagnosis, Prognosis, and Treatment Effectiveness

While there has been extensive research into the underlying biological basis of
mental disorders (including genetic, neurophysiological, and neuroanatomic
lines of inquiry), their underlying causes remain largely unknown (Cooper, 2016;
Perring, 2018), with the exception of some dementias and some intellectual
disabilities. As a result, most mental disorders are referred to as syndromes
(i.e., clusters of associated symptoms and signs) (Nasrallah, 2009; APA, 2013;
Murphy, 2017). To be diagnosed with a mental disorder, a person’s symptoms
and presentation must satisfy a certain number of that disorder’s diagnostic
criteria. Since people in the same diagnostic category can satisfy different
criteria, these categories contain considerable heterogeneity (APA, 2013;
Murphy, 2017). That is, two people can share the same diagnosis but have
different symptom profiles.
Furthermore, diagnoses of most mental disorders do not refer to specific

pathology within the body, and they often lack the stability of diagnoses of most
physical disorders. As a result, it can be difficult for clinicians to know when
they have reached a reasonable degree of certainty that a given diagnosis will
persist over time, the way they can with many of the physical conditions that
currently underlie most MAID requests in Canada (e.g., cancers and diseases of
the circulatory/respiratory system). If a person has lived with a mental disorder
for a long time, diagnostic change may be less likely. However, diagnostic stability
does not guarantee accurate prognostication (i.e., the prediction of the course of
the illness over time). For example, clinicians historically believed that borderline
personality disorder was a lifelong condition. However, longitudinal research
demonstrates that, for many people, a significant proportion of symptoms remit
over time (Gunderson et al., 2011), to the extent that the diagnosis ceases to
apply. Similarly, some people with substance-use disorders spontaneously remit
(even in severe cases), ceasing to use a substance after many years and with no
assistance of any kind, while others continue to use for years despite their desire
to stop and despite extensive medical and mental health support (Klingemann
& Sobell, 2007). Furthermore, with many mental disorders it is difficult to
predict which patients will remit and relapse, or be chronically affected.
While there exists a body of clinical research on the treatment of certain mental
disorders (e.g., major depressive disorder, schizophrenia, and bipolar disorder),
there is uncertainty surrounding the effectiveness of many standard treatments
(Cooper, 2007; Hautamäki, 2018). The syndromal nature of mental disorders
means that patient groups in clinical trials are often more heterogeneous
than those in clinical trials for physical diseases, which are selected with
careful attention to diagnostic homogeneity (Cooper, 2007). On the other
hand, attempts to more rigorously select for homogenous patient groups can
restrict the degree to which the results of a clinical trial can be generalized
(Tcheremissine et al., 2014). Furthermore, what counts as therapeutic efficacy in
clinical research is usually measured over relatively short periods of time (weeks
or months), whereas mental disorders can persist over much longer periods
of time. As a result, it can be difficult to predict the long-term effectiveness of
many psychiatric treatments (Cooper, 2007).
Even when clinical trial data suggest treatment efficacy, applying these data
to an individual patient’s context is not straightforward. The heterogeneous
nature of the diagnostic categories for mental disorders makes it difficult to
know which specific patient will benefit from which of the available treatments.
Systematic trial and error of available treatments is the primary method for
identifying effective treatment in a given patient. Some people benefit from
the first treatment they try, others pass through a series of individual and
combination treatments, while others are resistant to treatment.
While prognosis is therefore difficult to determine for many patients with a

mental disorder, it is possible to classify a patient’s mental disorder as being
treatment-resistant after a sustained period of treatment trial and error. In its
broadest sense, the term treatment-resistant refers to situations in which symptoms
of a person’s mental disorder have not been meaningfully reduced following a
certain number or type of treatments under appropriate conditions.7 However,

the term is also problematic, as there is no agreed-upon definition of what
constitutes treatment resistance (Berlim & Turecki, 2007; Conway et al., 2017;
Anderson, 2018). For instance, there is no consensus about what constitutes
meaningful or sufficient symptom reduction, about the proper number and
type of interventions that must be tried, or about the proper conditions under
which treatment attempts should occur. The term also tends to exclusively
refer to psychopharmacological treatments (i.e., medication) and excludes
psychological treatments such as therapy. Furthermore, there is little empirical
evidence that any of the various definitions of treatment resistance can help
predict a person’s future outcomes (Anderson, 2018). Indeed, treatment
resistance is a retrospective concept, and does not indicate that a person has
no hope of improvement (Blikshavn et al., 2017). It is also important to note
that treatment resistance refers to the reduction of the symptoms of a person’s
mental disorder, and not necessarily to the relief of suffering or a desire to
die. That is, there will be situations in which a person has a treatment-resistant
mental disorder but their suffering can be relieved or their desire to die can
be successfully treated.
Treatment response is further complicated by questions of treatment objective.

While traditional clinical research focuses on symptom reduction as the goal
of treatment, numerous commentators argue for other outcomes, including
quality of life, recovery, and acceptance (Anthony, 1993; Jacobson & Greenley,
2001; Davidson & O’Connell, 2005). For a given person, these outcomes may
or may not include symptom reduction. See Section 4.4.1 for a discussion of
the recovery movement in mental health, which focuses on what outcomes are
important to people with mental disorders.
The preceding discussion highlights the fact that there is usually less stability in
diagnosis, and poorer predictability in prognosis and treatment effectiveness,
for mental disorders compared to the physical conditions that typically motivate
MAID requests. Particularly when an apparent mental disorder is in its early
stages, it can be difficult to determine whether a problem is in fact a mental
disorder (diagnosis), and how that problem will evolve over time (prognosis).
It may also be difficult to know to what extent attempts to treat the condition
will relieve the person’s suffering (treatment effectiveness). However, there
will also be clinical circumstances in which there is a relatively higher degree
of certainty about these features, particularly when a person has suffered
7 The term treatment-refractory is sometimes used interchangeably with treatment-resistant, and is

sometimes taken to suggest a greater degree of resistance. However, it has been argued that this
distinction is somewhat arbitrary, and that the terms are in fact essentially synonymous (Berlim
& Turecki, 2007; Trevino, 2014).
over a long period of time despite repeated clinical attempts to alleviate that
suffering, or in the case of mental disorders that are associated with conditions
such as Huntington’s or Alzheimer’s disease, where the underlying pathology
is better understood.
3 .2 S UI C IDE
In its preamble, Bill C-14 acknowledges that suicide and MAID are related and
notes that “suicide is a significant public health issue that can have lasting and
harmful effects on individuals, families and communities” (GC, 2016b). This
section examines the prevalence of suicide in Canada, risk factors for suicide,
and the relationship between suicide and mental disorders. The relationship
between suicide and MAID MD-SUMC is discussed in Section 4.2.
At the beginning of the 19th century, it was a criminal offence to attempt suicide
in many countries, and survivors of suicide attempts could be prosecuted (Mishara
& Weisstub, 2016). The justification for criminalizing suicide was originally a
religious one (i.e., it was a sin or immoral act), and later a utilitarian one based
on the belief that the threat of punishment might reduce suicides. However, data
did not support the deterrence theory — rates do not increase when suicide is
decriminalized (Mishara & Weisstub, 2016). Furthermore, over the last century
the understanding of suicide has changed. It is now generally considered to be
associated with mental disorders and difficulty coping with social hardships,
rather than as an offence against moral or religious interdictions. Attempted
suicide was decriminalized in Canada in 1972 (Spiwak et al., 2012).
3.2.1 Suicide Rates and Risk Factors

Intentional self-harm was the cause of 1.5% of all deaths in Canada in 2016
(StatCan, 2018b), compared to 1.4% worldwide in 2012 (WHO, 2014a). The
age-specific mortality rate from suicide in Canada is more than triple for
men as compared to women (StatCan, 2018b). It is not possible to say what
proportion of suicides are completed by people facing intolerable suffering at
the end of life. In Canada, older people have a much lower suicide rate than
younger people; in 2016, intentional self-harm was the cause of death in 0.7%
of those aged 65 to 74, 0.3% in those aged 75 to 84, and 0.1% in those 85 and
older (StatCan, 2018b).
Although chronic pain and illness are listed as risk factors for suicide (WHO,
2014a), they are only two among a number of life circumstances that contribute
to increased suicide risk when there are insufficient protective factors (Mishara
& Tousignant, 2004; WHO, 2014a). Research indicates that physical conditions
are among the less frequently mentioned reasons for wanting to die in those who
attempt suicide (Wang et al., 2015; Burón et al., 2016). More common reasons
include macro-level variables such as unemployment; individual demographic
characteristics such as gender, age, and marital status; a wide range of social
variables (e.g., social support); and the psychological characteristics of the
person (e.g., personality traits, coping strategies) (Mishara & Chagnon, 2016).
Certain environmental variables, particularly access to means of suicide, are
also associated with an increased risk of a suicide attempt (WHO, 2014a).
The most widely held view among suicide researchers is that suicide is a multi-
determined outcome that occurs when individual and contextual risk factors
outweigh protective factors (WHO, 2014a; Mishara & Carindal, 2015). These
factors have been identified through a substantial body of empirical research
(Mishara & Tousignant, 2004).
There are multiple factors associated with suicide risk apart from having a mental
disorder (Mishara & Tousignant, 2004; WHO, 2014a). Having a mental disorder
is, however, one of the most strongly associated risk factors for suicide (WHO,
2014a; Mishara & Carindal, 2015). Systematic reviews and meta-analyses have
found that up to 90% of those who die by suicide may have had a diagnosable
psychiatric disorder (as determined by a retrospective psychological autopsy)
(Cavanaugh et al., 2003; Arsenault-Lapierre et al., 2004). Studies show that
the most common diagnoses are affective disorders (particularly depression),
substance use disorders, personality disorders, and schizophrenia. The lifetime
risk of completed suicide is estimated to be 2% for people with affective
disorders (Bostwick & Pankratz, 2000), 5% in people with schizophrenia
(Palmer et al., 2005), 8% in people with alcohol dependence (Schneider, 2009),
and 8% in people with bipolar disorder (Nordentoft et al., 2011). Although
most mental disorders are associated with an increased suicide risk, there are
a few exceptions. For example, people with a diagnosis of dementia generally
do not have a higher risk of dying by suicide, except in cases of Huntington’s
disease, and during the period directly following diagnosis (Haw et al., 2009).
Research shows that the majority (approximately 85%) of people who seriously
consider suicide will never attempt it (Nock, 2008), and fewer than 5% of those
who attempt suicide will die (WHO, 2014a). Most people who attempt suicide
are ambivalent about wanting to die — unclear, uncertain, and/or unstable
wishes are common in this population (WHO, 2014a). Ambivalence about
dying is considered to be a primary characteristic of the desire to kill oneself
(Kastenbaum, 2003), and it fluctuates with a person’s experiences, including
the experience of initiating a suicide attempt (Bergmans et al., 2017). Kevin
Hines provides a dramatic example. He was diagnosed with bipolar disorder,
attempted suicide by jumping off the Golden Gate Bridge in San Francisco
in 2000, and later reported that he had no doubts about his plan until he
was falling from the bridge (Hines, 2013). This example illustrates how a
person’s decision to die by suicide is not a binary choice, and may be at odds
with the usual characterization of healthcare decision-making as a process of
gathering information and choosing among options (Appelbaum & Grisso,
1988). To complicate matters further, although rare, some people impulsively
kill themselves with little advance warning (WHO, 2014a).
The lay understanding of the relationship between mental disorders and

suicide is that suicide is a direct consequence of a mental disorder (Mishara &
Chagnon, 2016). According to this model, the symptoms of a mental disorder
are a determining factor in the desire to die and engaging in suicidal behaviours.
For example, depressive symptoms may alter a person’s perceptions of reality,
such as perceiving their situation as hopeless when their prognosis may actually
be positive (Berghmans et al., 2013; Hindmarch et al., 2013; Blikshavn et al.,
2017). Other explanations of the relationship between mental disorders and
suicide suggest that psychosocial factors resulting from living with a mental
disorder (e.g., social isolation, stigma, unemployment, poor social supports)
increase suicide risk (Mishara & Chagnon, 2016). However, no reasons for
suicidal thinking are associated with more or less determination to die or the
persistence of these desires. And in both models, interventions exist (medical,
psychological, social) that reduce risk (Mishara & Chagnon, 2016).
3 .3 P R E VAL E NCE AND S OC I O-E CONOMIC /DEMOGR APH IC

C O R R E L AT E S OF M E NTAL DI S O R DER S, AND
A C C ES S T O M E NTAL H E ALT H CAR E IN C ANADA
This section provides an overview of the prevalence of mental disorders in

Canada (Section 3.3.1), the socio-economic and demographic correlates of
mental disorders (Section 3.3.2), the history of care for people with mental
disorders in Canada (Section 3.3.3), and access to mental healthcare services
and supports in Canada (Section 3.3.4).
3.3.1 Prevalence of Mental Disorders

Table 3.1 summarizes the prevalence of certain mental disorders in Canada
(i.e., estimates of the number of cases at a given point in time), but the data
sources are not robust. These data are partially drawn from the 2012 Canadian
Community Health Survey (CCHS), which provides an estimate of the prevalence
of mental health problems at the sub-provincial and territorial level in Canada.
However, because these data are based on self-reported symptoms rather than
clinical diagnoses (MHCC, 2014a; StatCan, 2016), they may under-represent
less common mental disorders and psychoses. The CCHS data in Table 3.1
are complemented by data drawn from clinical research, as well as data from
administrative sources that include inpatient treatment settings.
Table 3.1
Prevalence of Various Mental Disorders in Canada
Mental Disorder* Status in Canada

Mood Disorders In 2012, 12.6% of people in Canada aged 15 years and older (about
(e.g., major 3.5 million) met the criteria for a mood disorder (including a major
depressive disorder, depressive episode or bipolar disorder) in their lifetime (Pearson et al.,
bipolar disorder) 2013). Mood disorders were most prevalent in youths aged 15–24 with
8.2% having experienced a mood disorder over the past year. Rates of
mood disorder over the previous 12 months were lowest in those aged 65
and older (1.7%). Women (5.8%) had higher 12-month rates of mood
disorder than men (3.6%) in all age groups except for 65+ (Pearson et al.,
2013).
Post-Traumatic Stress In 2008, lifetime prevalence of post-traumatic stress disorder (PTSD) in
Disorder Canada was estimated to be 9.2% (about 3 million people) (Ameringen et
al., 2008).
Generalized Anxiety In 2012, 8.7% of people in Canada aged 15 years and older (about
Disorder 2.4 million) met the criteria for generalized anxiety disorder (Pearson et al.,
2013).
Major Neurocognitive About 7.1% of people in Canada 65 years and older (about 402,000) live
Disorders with dementia, two-thirds of whom are women. Both the prevalence of
(e.g., Alzheimer’s dementia and the risk of developing dementia increase with age, “as does
dementia) the differential in prevalence and incidence estimates between men and
women” (PHAC, 2017).
Personality Disorders No Canada-specific data could be found about the prevalence of
personality disorders. However, they are estimated to affect between
6–15% of the adult population (APA, 2013; Gawda & Czubak, 2017).
Somatic Symptom Data about the prevalence of somatic symptom disorders are inconsistent,
Disorders and no Canada-specific prevalence data could be found (except in pediatric
(e.g., conversion settings). However, the DSM-5 estimates the prevalence of somatic
disorder) symptom disorders to be approximately 5–7% in the general adult
population, and more prevalent in women than in men (APA, 2013).
Schizophrenia or In 2012, 1.3% of people in Canada (about 360,000) had received a
Psychosis diagnosis of schizophrenia or psychosis in their lifetime (StatCan, 2013).
Eating Disorders In 2012, 0.4% of people in Canada (about 113,000), had a diagnosis of an
(e.g., anorexia eating disorder (StatCan, 2013). The hospitalization rate for eating
nervosa, bulimia disorders among women and girls in 2012-2013 was 15 times that of men
nervosa) and boys (CIHI, 2014).
* Individuals may have more than one mental disorder.
3.3.2 Socio-Economic and Demographic Correlates of

Mental Disorders
Mental disorders can affect people in all socio-economic and demographic
categories (GC, 2002), but the presence of many mental disorders is strongly
correlated with certain social, economic, and environmental inequalities
(WHO, 2014b), such as poverty, unemployment, homelessness, and violence

(Kirby & Keon, 2006; CIHI, 2007; WHO, 2010; CMHA Ontario, 2011; MHCC,
2014b). Canadian data show that women, youth, and Indigenous people have
higher rates of mental health problems than the Canadian average (GC, 2006;
StatCan, 2013, 2015b). Depression, anxiety disorders, and eating disorders are
more common in women, and are strongly associated with women’s greater
exposure to poverty, discrimination, socio-economic disadvantage, and gender-
based violence. On the other hand, there is no noticeable gender difference
with respect to bipolar disorder or schizophrenia (WHO, 2001).
The relationship between social factors and mental disorders is complex and
bi-directional: social factors can increase a person’s risk of developing a mental
disorder, and having a mental disorder can increase a person’s exposure and
vulnerability to social factors that are detrimental to their mental health (WHO,
2014b; Mental Health Foundation, 2016; Carod-Artal, 2017). As Chandler (2016)
writes, “while social marginalization can raise the risk of experiencing a mental
health disability, those disabilities also often lead to social marginalization, with
higher rates of homelessness and incarceration than the rest of the population.”
People living with mental disorders often lack equity in access to educational
and employment opportunities, and may lack family or social relationships that
could help support recovery (GC, 2002; WHO, 2010; MHCC, 2015). The care
requirements and stigma surrounding mental disorders can strain families, often
leading to further social isolation (GC, 2002). People with mental disorders are
heavily overrepresented in the homeless population, and family relationships
have been found to be a significant variable in exiting homelessness (Bonin
et al., 2017). For example, while schizophrenia has a worldwide prevalence of
approximately 1%, people with schizophrenia account for 11% of the homeless
population worldwide (Bonin et al., 2017). People with mental disorders have
an increased risk of being the victim of crime, physical or emotional abuse,
and sexual assault (Teplin et al., 2005; McFarlane et al., 2006; WHO, 2010;
StatCan, 2015a). Worldwide, they face restrictions on their civil rights, and
may be denied the opportunity to make decisions for themselves and manage
their lives (WHO, 2010).
People with mental disorders also face additional challenges with respect to their
physical health and are at higher risk of developing chronic physical disorders
(including but not limited to diabetes, heart disease, stroke, and respiratory
disease) (Price et al., 2007; CMHA, 2008). They are less likely than those
living without mental disorders to receive needed treatments for such physical
disorders (Kisely, 2007; CMHA, 2008). They may also engage in behaviours
that increase the risk of developing complications or other disorders, such as
smoking and substance use (CMHA, 2008).
3.3.3 A Brief Historical Overview of the Care of People

with Mental Disorders
The history of treatment of those with mental disorders in Canada is important
context for examining MAID MD-SUMC. Before the establishment of a formal
system of care in Canada, including publicly funded mental health institutions,
people with mental disorders were often placed in prisons or almshouses, or
were left in the care of their families or to fend for themselves (Sussman, 1998;
Dowbiggin, 2011). As colonialism expanded across Canada, a network of what
were then called “lunatic asylums” was established prior to Confederation
and continued to be developed throughout the 19th century (Moran, 2001;
Dowbiggin, 2011). By the early 20th century, the formal diagnosis of mental
disorders was rising and more people were being committed to institutions,
which created crowding and funding challenges for government operators
(Dowbiggin, 2011; Niles, 2013). Most of the people living in institutions were
under medical supervision and received varying degrees of psychiatric treatment.
In the latter half of the 19th century, the eugenics movement was used to explain
the growing numbers of registered “insane,” blaming defective heredity and
“mentally unsound” immigrants arriving on Canadian soil (McLaren, 1997;
Chadha, 2008; Strange & Stephen, 2010). In 1921, the Canadian National
Committee for Mental Hygiene recommended sexual sterilization of people
with mental disorders (Amy & Rowlands, 2018). British Columbia and Alberta
passed sterilization legislation to ensure that “mentally defective” individuals
would be prevented from reproducing (Dyck, 2013). In Alberta, the Sexual
Sterilization Act, in force from 1929 to 1972, created the Alberta Eugenics Board,
which allowed for the sterilization of people living in mental health institutions
as a condition for their release into the community. Evidence suggests that
women and Indigenous people were disproportionately sterilized as part of
this program, and that in many cases sterilization was undertaken without the
person’s consent (Grekul et al., 2004; Boyer & Bartlett, 2017).
In the first half of the 20th century, both the medical community and the public
generally supported sterilization programs (Dowbiggin, 1997; McLaren, 1997).
In the view of the Working Group, supporters of sterilization justified such
practices on the basis of a widely held belief that the lives of people with mental
disorders were less valuable than the lives of those without. Although the eugenics
movement was discredited following World War II, the mistreatment of people
with mental disorders in the healthcare system continued; paternalistic practices
restricted civil liberties and denied people choices, freedoms, and autonomy.
One well-reported example of such practices occurred in the 1950s and 1960s.
The Allan Memorial Institute in Quebec experimented on psychiatric inpatients
without their knowledge or consent as part of the CIA’s MK-ULTRA mind
control program. These experiments were partially funded by the Canadian
government, and included intensive electroconvulsive therapy (ECT), sleep
and sensory deprivation, administering LSD to patients, and putting people
in drug-induced comas (CBC, 2017a). In Ontario, the Oak Ridge Psychiatric
Unit, a maximum-security mental health facility, used similar techniques on its
patients between 1966 and 1983 (Power, 2017). In 2017, the Ontario Superior
Court of Justice found that, although such techniques were part of generally
accepted medical practices of the time and may even have been undertaken in
good faith, the methods employed at Oak Ridge “were torture and a degradation
of human dignity” (ONSC, 2017).
The deinstitutionalization of people with mental disorders began in the 1950s

and accelerated in the 1960s and 1970s in Canada. This movement reflected
the growing knowledge of mental health rehabilitation practices; a growing
emphasis on the civil liberties of patients with mental disorders; the impact of new
psychopharmacological therapies; acknowledgement of the harms and abuses
in the institutional care system; as well as the desire of provinces to reduce costs
(Morrow et al., 2008; Flood & Thomas, 2016). As part of the deinstitutionalization
movement, a number of large mental health institutions were either downsized
or phased out entirely, with patients discharged into community care settings.
However, community mental health options in the 1980s and 1990s were not
provided with sufficient resources to respond to the growing need for care
in the community (Epp, 1988; Commission on the Future of Health Care in
Canada, 2002; Romanow & Marchildon, 2003; Flood & Thomas, 2016; Dyck
& Deighton, 2017). This contributed to high readmission rates of people with
mental disorders to psychiatric units, the growing problem of homelessness
among people with mental disorders, and the overrepresentation of people
with mental disorders in the criminal justice system. While many instances of
injustice towards people with mental disorders in Canada and abroad occurred
in the past, there continues to be mistreatment today.
In the view of the Working Group, the history of mistreatment of many people with
mental disorders in the delivery of healthcare — the early asylums, the eugenics
movement, the institutional abuses of the mid-20th century, and the failure to
provide sufficient resources following deinstitutionalization — demonstrates
how such people could be vulnerable to further mistreatment in the context
of MAID MD-SUMC. On the one hand, prohibiting MAID MD-SUMC may be

seen as perpetuating paternalistic practices that restrict the civil liberties of
people with mental disorders, and deny them freedom, choice, and autonomy.
On the other hand, permitting MAID MD-SUMC more broadly may be seen
as perpetuating an ideology that devalues people with mental disorders by
suggesting that their lives may not be worth living and by promoting civil
liberties without providing necessary resources.
3.3.4 Access to Mental Healthcare Services

Many people with mental disorders do not receive the necessary treatment for
their condition (WHO World Mental Health Survey Consortium, 2004; MHCC,
2016b). This is because they may be reluctant to seek mental healthcare due
to stigma (CMHA, 2008; Knaak et al., 2017), or they may be unable to access
mental healthcare for a variety of reasons (discussed further below). In 2012,
10.9% of people in Canada reported accessing a professional mental healthcare
service (StatCan, 2013). At the same time, in 2012, 26.3% of people in Canada
aged 12 and older with a mental disorder reported that they perceived a need
for mental healthcare in the past year but did not receive it (MHCC, 2016a).
In 2014 and 2015, more than 222,000 Canadian hospital stays were a result of
mental health or addiction issues (CIHI, 2016). Factors that may impede access
to mental healthcare services are presented in Box 3.1.
Box 3.1
Some Impediments to Accessing Mental Healthcare
Some impediments to accessing mental healthcare include:

• lack of access to primary care providers (Ross et al., 2015);
• primary care providers who are insufficiently trained in the delivery of mental
healthcare (Ross et al., 2015; Flood & Thomas, 2016);
• long wait times for psychiatrists (Flood & Thomas, 2016);
• lack of access to psychiatrists, especially in rural and remote areas (Slaunwhite,
2015; McKenzie et al., 2016);
• inadequate or absent insurance coverage for medications, psychological services,
rehabilitative measures, and other types of outpatient treatment (Flood & Thomas,
2016);
• lack of social supports (e.g., subsidized housing and/or transportation) (Ross et
al., 2015; Slaunwhite, 2015); and
• stigma towards people with mental disorders (Ross et al., 2015; Slaunwhite, 2015;
Knaak et al., 2017).
Given that living with mental disorders is often correlated with poor socio-
economic status, that mental health-promoting services can be difficult to access,
and that improving mental health often requires access to a broad array of
resources beyond medical care (such as income stability, secure housing, and
social support), there is the possibility that people who seek MAID MD-SUMC
may be individuals who are socially and economically marginalized. In support
of this, a qualitative study of patients who requested euthanasia or physician-
assisted suicide for psychiatric disorders (psychiatric EAS) in the Netherlands
found that, in some cases, a lack of socio-economic resources contributed to
their suffering (Verhofstadt et al., 2017). On the other hand, a 2007 study of
requests for assisted dying in Oregon and the Netherlands suggests that people
who enjoy comparatively higher social, economic, and educational privilege
are more likely to access MAID than those who are marginalized (Battin et al.,
2007). However, Oregon does not allow assisted dying in cases where a mental
disorder is the sole underlying medical condition, and the study does not
disaggregate requests for psychiatric EAS in the Netherlands from all requests
for EAS in that country. Indeed, data on socio-economic and demographic
variables related to requests for assisted dying specifically for mental disorders
in jurisdictions that allow it are almost nonexistent,8 so the Working Group
could not extrapolate the demographic and socio-economic status of MAID
MD-SUMC requesters from all assisted dying requesters. The socio-economic
and demographic characteristics of people with a mental disorder who request
MAID MD-SUMC may be different from those who request MAID for a physical
condition.
3 .4 I N D I GE NOU S P E OP L E AND M ENTAL H EALTH
According to the 2016 Census, there were 1,673,785 Indigenous people in

Canada in 2016, accounting for approximately 4.9% of the total population
(StatCan, 2017a). Although there is great heterogeneity among individuals,
Indigenous people overall experience mental health issues at a higher rate than
the non-Indigenous population (StatCan, 2015b). Nearly 39% of Indigenous
people in Canada live in rural areas (StatCan, 2018a), and may have limited
access to formal mental health supports. While 30% of Indigenous people in
Canada live in large population centres and consequently should have better
access to mental healthcare, some individuals experience racism as they navigate
the mental healthcare system and/or cannot access culturally appropriate and
safe mental healthcare (Allan & Smylie, 2015; Boksa et al., 2015), in addition to
facing the impediments to care listed in Box 3.1. Direct and intergenerational
traumas or past discrimination within the healthcare system may deter some
Indigenous people from seeking needed mental healthcare (Boksa et al., 2015).
8 The two exceptions to the lack of demographic data on people who request psychiatric EAS
are gender and age (see Sections 3.5, 5.5, and 6.3).
In addition, there is a general lack of attention paid to Indigenous knowledge

and understanding of mental health in the Canadian healthcare system (Boksa et
al., 2015; Stewart & Marshall, 2017), which may differ significantly in important
ways from Western conceptions of mental health (Oulanova & Moodley, 2017).
Rates of suicide among Indigenous people are disproportionately high. Among

First Nations, the suicide rate is roughly double that of the total Canadian
population (Kirmayer et al., 2007). This disparity is even more pronounced
among Indigenous youth. The suicide rate for First Nations youth living on
reserve is five to seven times higher than for non-Indigenous youth. In Inuit
youth, the suicide rate is 11 times higher (GC, 2016a). There have been
clusters of Indigenous youth suicides in communities such as Attawapiskat
First Nation in Ontario (Spurr, 2016), Pimicikamak Cree Nation in Manitoba
(Puxley, 2016), and across northern Saskatchewan (Cowan, 2016). The Truth
and Reconciliation Commission’s (TRC) report connects the disparity in
suicide rates and other health outcomes in Indigenous communities directly
to Canada’s colonial legacy, including residential schools and a reserve system
that “separated Aboriginal people from their traditional lands and livelihoods,
confining them to cramped and inadequate housing on reserves that lacked the
basic sanitary services” (TRC, 2015b). In the view of the Working Group, the
potential impact of MAID MD-SUMC, if any, on suicide prevention efforts is
an issue that will need to be explored more deeply with Indigenous people.
Further, Indigenous knowledge and practices related to death and dying
generally may be unknown or unexplored by healthcare practitioners when
discussing end-of-life issues with Indigenous patients (Kelly & Minty, 2007).
3 . 5 O THE R S P E CI F I C P OP U L AT I ONS AND MENTAL H EALTH
In Canada, different gender, ethnic, cultural, socio-economic, and demographic

groups experience differences in the prevalence of and risk factors for mental
disorders, suicidality, and access to mental healthcare and social supports. In
addition, certain unique issues related to capacity, voluntariness, vulnerability,
discrimination, or other factors may apply to specific populations such as
children, seniors, and institutionalized individuals. This section examines issues
related to mental health and mental disorders for specific sub-populations in
Canada. See Section 6.3 for a discussion of the potential implications for these
groups should MAID MD-SUMC be prohibited or permitted more broadly.
Gender
There is evidence that women in Canada experience certain mental disorders
at a higher rate than men (Pearson et al., 2013). In addition, women in Canada
are three to four times more likely to attempt suicide than men, although men
are more likely to die by suicide (StatCan, 2017c). Mental disorders such as
depression, anxiety, eating disorders, body image problems, and PTSD following
sexual abuse and other gender-based violence cannot be attributed only to
biology, or divorced from cultural, gender-related factors and the unequal
power structures that women face (WHO, 2001).
Gender (along with age) is one of the two exceptions to the paucity of data
on demographic factors associated with psychiatric EAS in international
jurisdictions. Evidence from Belgium and the Netherlands show that more
women than men have requested and accessed psychiatric EAS (Groenewoud
et al., 1997; Thienpont et al., 2015; Kim et al., 2016). It is unclear whether
the greater number of women seeking psychiatric EAS in Belgium and the
Netherlands is proportionate to their incidence of mental disorders. The ratio
of women to men requesting psychiatric EAS in the Netherlands (2.3 to 1)
is nearly identical to the ratio of women to men attempting suicide in the
Netherlands (Kim et al., 2016).
Sociocultural and Racialized Groups

Mental disorders do not affect all populations in Canada equally. Immigrant,
refugee, ethnocultural, and racialized (IRER)9 populations are found to have
lower rates of mental disorders compared to the general population when
investigated as a single group (McKenzie et al., 2016). However, this approach
obscures the diversity within IRER groups, and the specific mental health
challenges faced by individuals in these groups (McKenzie et al., 2016). IRER
individuals and groups are more likely to experience racial discrimination
and other social inequalities that increase the risk of mental disorders and
decrease the rate of recovery from mental health problems. For example,
people in IRER groups often experience workforce discrimination, leading
to difficulty earning a decent income or obtaining adequate housing, factors
that are key social determinants of mental health. They are also less likely to
have equitable access to culturally appropriate and effective mental healthcare
and social supports that take their specific needs into account (MHCC, 2012).
9 Racialized is a term used in lieu of sometimes-inaccurate terms such as minority or person of

colour. Using the term racialized acknowledges the social construction of race (McKenzie et al.,
2016). Sociocultural groups are those that share “common ancestry and cultural characteristics”
(McKenzie et al., 2016). The grouping of immigrant, refugee, ethnocultural, and racialized
populations, and the acronym IRER, are adapted from a 2016 Mental Health Commission of
Canada report on improving mental healthcare services in these populations (McKenzie et al.,
2016). The Working Group decided to group IRER populations together due to a paucity of
available population-specific evidence and data.
However, there is significant variability in the rate of certain mental disorders

within different generations of the same ethnic group, among different country-
of-origin groups, and among immigrant and refugee groups. For example,
recent immigrants are less likely to report depression than immigrants who
have been in Canada for a longer period of time (the “healthy immigrant”
effect) (Stafford et al., 2010). Rates of depression in longer-term immigrants
to Canada are more similar to the general Canadian population (Stafford et
al., 2010). With each year of residence in Canada, the healthy immigrant effect
diminishes (Ng, 2011; Patterson et al., 2012).
People in IRER groups can face a number of challenges in accessing mental

healthcare services. These barriers include service accessibility, difficulties in
patient-provider interaction, circumstantial challenges (e.g., transportation,
ability to pay, isolation), language barriers, stigma, and fear (McKenzie et al.,
2016). The experience of racism in and of itself can negatively affect mental
health (Nestel, 2012), and systemic racism against IRER groups exists in the
Canadian healthcare system (SHS, 2017). Culture also plays a role in how
barriers to mental healthcare are experienced by people in IRER groups. Some,
particularly recent immigrants, may have difficulty navigating the Canadian
healthcare system and in finding care that is culturally appropriate (Koehn,
2009). In all cultural groups, stigma about mental disorders may delay an
individual from reaching out for help (McKenzie et al., 2016). Having a first
language other than English or French may also affect a person’s ability to
obtain help and follow professional advice (McKenzie et al., 2016).
LGBTQ+ People
While the LGBTQ+ community is diverse, those who identify as such are overall
at greater risk of experiencing certain mental disorders compared to the rest
of the population, including anxiety disorders, mood disorders, and substance
use disorders (Diamant & Wold, 2003; Cochran & Mays, 2007; McCabe et al.,
2010; MHCC, 2016a; Pakula et al., 2016). Lesbian, gay, and bisexual people
have double the risk for PTSD as compared to heterosexual people (Roberts
et al., 2010). Studies have further demonstrated that lesbian, gay, bisexual, and
transgender people are more at risk of suicide (Bauer et al., 2010; Benibgui,
2010; Bauer & Scheim, 2015). Lesbian, gay, and bisexual people in Canada
are also more likely to both consult a mental healthcare practitioner and state
they have unmet mental healthcare needs as compared to heterosexual people
(Tjepkema, 2008). The reasons for these mental health challenges are complex,
but seem to include the stigma, discrimination, and family rejection faced by
some people in the LGBTQ+ community, as well as their greater risk of being
the target of assault and harassment (Meyer, 2003; Pascoe & Smart Richman,
2009; Benibgui, 2010). The stress associated with modifying behaviour or

concealing sexual orientation may also have negative impacts on mental and
physical health (Selvidge et al., 2008; Pascoe & Smart Richman, 2009).
Seniors
Dementia is more common among older people as compared to other
demographic groups. Other mental disorders also have an impact on older
adults, who have a higher risk of developing depression, especially beyond
75 to 80 years of age (McCrone et al., 2008).
In high-income countries, mental health inequalities among older people

are correlated with socio-economic status, among other factors (Allen, 2008;
McCrone et al., 2008). Seniors in Canada are more likely to be considered
low-income than other adults. People living on low incomes may have greater
challenges in accessing mental healthcare services. Older people also have a
higher risk of social isolation because of the greater chance of compromised
health status, living alone, death of family or friends, changing family structures,
and retirement (The National Seniors Council, 2014).
Youth (Mature Minors)

Prognosis of mental disorders is particularly difficult in young people because
they are in the process of rapid and significant change during adolescence,
and because they have a shorter treatment history and/or less experience
coping with symptoms. Current evidence indicates that brain development is
not complete until approximately 25 years of age (Giedd, 2015); it is therefore
even more difficult for a clinician to confidently determine whether a minor’s
mental disorder is irremediable as compared to adults over the age of 25.
Suicide is the second-leading cause of death for people in Canada aged 15 to

24, and the leading cause of death for those aged 10 to 14 (StatCan, 2017c).
As mentioned in Section 3.4, the suicide rate for First Nations youth living on
reserve is five to seven times higher than for non-Indigenous youth. In Inuit
youth, the suicide rate is 11 times higher (GC, 2016a).
Canadian Armed Forces Members and Veterans

Active Canadian Armed Forces members have significantly higher rates of major
depression, generalized anxiety disorder, and suicidal ideation compared to
the general population (Rusu et al., 2016), and there is evidence these higher
rates extend to veterans (Mahar et al., 2017). Studies have found that Canadian
Armed Forces members, particularly those with suicidal ideation, may have
better access to mental healthcare services that meet their needs as compared
to the general population (Fikretoglu et al., 2016; Sareen et al., 2017). However,
a 2014 report by the Auditor General of Canada found that, despite putting in
place important mental health supports for veterans, “Veterans Affairs Canada
is not adequately facilitating timely access to mental health services,” and that
the agency’s “mental health outreach strategy is not comprehensive enough”
(AGC, 2014).
Incarcerated People
Mental disorders are prevalent and rates are increasing among incarcerated
people. Their rates exceed that of the general population (Service, 2010).
Further, the suicide rate of those incarcerated in federal facilities is more than
seven times the Canadian average (Service, 2010), and Canada faces “significant
shortfalls” in meeting the mental healthcare needs of people in the criminal
justice system (MHCC, 2012).
Incarceration may also complicate the assessment of capacity, since little is

known about how life in prison affects decisional capacity for people with
mental disorders; there may also be unique issues of undue influence (e.g.,
by correctional officials, other inmates, or gangs). Suicidality is treated as a
risk in correctional settings, and attempts or indications of attempts may lead
to solitary confinement. Incarcerated people may therefore resist expressing
a considered desire to die if they fear being put on suicide watch or having
their freedoms curtailed (ICEL2 Satellite Workshop on Medical Assistance in
Dying for Canadian Prisoners, 2017).
3 . 6 LE G A L LA N DS C AP E F OR M E NTAL H E ALTH AND MAID
In Canada, much of the legal authority for mental healthcare and treatment
is based on the common law and, where statutory, falls within provincial/
territorial jurisdiction — this includes laws relating to voluntary and involuntary
hospitalization, capacity determination, requirements for informed consent,
and human rights legislation. The Canadian Charter of Rights and Freedoms also
provides guidance on these issues, as do decisions by the Supreme Court of
Canada. The federal government is responsible for Canada’s Criminal Code,
which sets out the legal conditions under which MAID can be provided.
3.6.1 The Law on Informed Consent

The common law and Quebec’s Civil Code underscore the requirement that a
patient must provide consent before medical treatment, and that such consent
be “voluntary, informed and capable” (Wildeman, 2016). A number of provinces
and territories have further codified these requirements. Section 7 of the
Canadian Charter of Rights and Freedoms has also been interpreted to include a
right to informed consent. For example, in the unanimous judgment in Carter
v. Canada, the Supreme Court of Canada noted:
The law has long protected patient autonomy in medical decision-

making […] “[C]ompetent individuals are — and should be — free to
make decisions about their bodily integrity” […] This right to “decide
one’s own fate” […] underlies the concept of ‘informed consent’ and
is protected by s.7’s guarantee of liberty and security of the person
[…] [T]he right of medical self-determination is not vitiated by the
fact that serious risks or consequences, including death, may flow from
the patient’s decision.
(SCC, 2015)
Informed consent in Canada must be voluntary, but mental disorders complicate

this requirement. For example, in some provinces and territories, a person may
be chemically or physically restrained unless medication is taken if they pose a
danger to themselves or others due to their mental disorder (Wildeman, 2016).
Further, for informed consent to be valid, a person must have the capacity to
provide such consent (this issue is examined in more detail in Section 4.1.1).
There is disagreement over whether people with mental disorders should have
the right to refuse treatment when they have been involuntarily hospitalized, even
if they are deemed to have legal capacity. This debate has been characterized
as a contest between the need for treatment view and the civil libertarian view:
From the treatment-oriented perspective, autonomy and dignity are

eroded by untreated mental illness, and can be restored by treatment.
This “need for treatment” approach tends to favour a lower threshold for
involuntary intervention in order to promote the medical “best interests”
of people with mental health problems. From the civil libertarian
perspective, however, forcing an intervention on an unwilling person
harms liberty and dignity. A strict civil libertarian approach would
intervene only where a person poses an unreasonable threat to others.
(Chandler, 2017)
The civil libertarian stance, which focuses on fundamental individual rights, is

in part a response to the belief that psychiatric treatment in the past too often
included the non-consensual use of interventions that, in retrospect, had dubious
scientific validity (SSO, 2013). This stance arose in the context of the general
movement towards patient autonomy, the rise of the civil rights movement, a
growing cultural backlash against invasive treatments such as lobotomy and

non-consensual ECT, and the desire of some patients and their supporters to
protect bodily integrity against treatments perceived — as Wildeman (2016)
describes — as “profound identity-annihilating violence.” In contrast, the need
for treatment view argues that treatment may be in a person’s best interests
(even if it goes against their wishes) and, in some cases, respect for a patient’s
autonomy requires considering the impact of non-treatment on the patient,
their family, and others (Section 4.3.2). The latter stance also notes the harm
caused by deinstitutionalization, which was driven by civil libertarian values,
and which failed to adequately support people with mental disorders in the
community (Section 3.3.3).
3.6.2 Capacity to Make a Decision with Respect to One’s Health

Capacity is a legal concept that is applied in clinical practice when healthcare
decisions must be made.
In Canada, all adults are presumed to have the legal capacity to make medical
decisions, and “the onus lies on the one challenging capacity to rebut this
presumption” (Wildeman, 2016). Capacity is always assessed relative to a
particular decision, and a person might have capacity to make some decisions
but not others (Gilmour, 2017). Provincial and territorial legislation typically
places responsibility for determining capacity on healthcare practitioners.
During a capacity assessment, a healthcare practitioner must determine whether
a person’s abilities are sufficient to meet the relevant legal test for capacity.
While there is no single, uniform test or definition of capacity in Canadian

law (Bach & Kerzner, 2010), a two-criteria test that focuses on two particular
abilities — (i) the ability to understand information relevant to making a decision,
and (ii) the ability to appreciate the reasonably foreseeable consequences
of a decision — can be found in several pieces of provincial and territorial
legislation, including Ontario’s Substitute Decisions Act and Health Care Consent
Act, Saskatchewan’s Adult Guardianship and Co-decision-making Act, and Manitoba’s
Vulnerable Persons Living with a Mental Disability Act (MLRC, 2004; Bach &
Kerzner, 2010; OHA, 2016; CPSS, 2017). The criteria of the understand/
appreciate test were also affirmed by the Supreme Court of Canada in Starson
v. Swayze (SCC, 2003).
The “understanding” criterion requires that the patient be able to comprehend

information such as the medical condition(s) that the treatment is intended
to address, the nature of that treatment, the potential risks and benefits of the
treatment, and any alternatives to the proposed treatment, including electing
to forego the treatment (CPSS, 2017; Deschamps, 2017b). The “appreciation”
criterion often proves more complex; to meet this test, a person generally
must admit they have symptoms, even if they disagree with the diagnostic label
given to the condition (SCC, 2003; Dull, 2009). The person must also be able
to apply the information presented to them to their own situation and assess
how the proposed treatment (or lack of treatment) may affect their quality of
life (CPSS, 2017).
Box 3.2
Incapacity due to Failing to Satisfy the “Appreciation”
Criterion: Two Examples
A patient diagnosed with schizophrenia is able to understand the information about

the illness, and that it can affect some people, but does not believe that they have
that illness, in spite of a two-year history of symptoms consistent with schizophrenia,
hospitalization, and treatment.
A patient diagnosed with anorexia nervosa is able to understand and intelligently

discuss the nature and consequences of the illness and readily acknowledges that
people have to eat or may die. In spite of this, the patient is not able to eat and
maintains that they will be fine.
Excerpted from OHA (2016)
The Supreme Court of Canada has recognized that people with mental disorders
risk being unduly assumed to lack capacity. In Starson v. Swayze, Justice Major,
writing for the majority, cited a 1990 report by Ontario’s Committee on the
Enquiry on Mental Competency (Weisstub, 1990), stating:
The tendency to conflate mental illness with lack of capacity, which

occurs to an even greater extent when involuntary commitment is
involved, has deep historical roots, and even though changes have
occurred in the law over the past twenty years, attitudes and beliefs
have been slow to change. For this reason it is particularly important
that autonomy and self-determination be given priority when assessing
individuals in this group.
(SCC, 2003)
In some provinces and territories, a patient can challenge a determination of

incapacity (for example, in Ontario a person can appeal a finding of incapacity
to the Consent and Capacity Board). If it is determined that a person lacks the
capacity to make a healthcare decision, then treatment decisions are normally

made by a substitute decision-maker (SDM). The SDM is usually a family
member, and if there are none, the Public Guardian (Wildeman, 2016). SDMs
must follow one of three legislated approaches (which vary by province and
territory) when making a decision on behalf of those they represent: (i) respect
a patient’s prior wishes, if known and made when capable; (ii) determine
what is in the patient’s best interest; or (iii) use a hybrid model that requires
compliance with prior known wishes unless this would endanger the physical
or mental health of the patient or a third party (Wildeman, 2016).
3.6.3 Involuntary Admission and the Right to Refuse Treatment

Provincial and territorial mental health legislation sets out the criteria for
involuntary admission to a psychiatric facility and involuntary treatment (see
Appendix B for a list of mental health legislation in individual jurisdictions).
Generally, mental health laws set limits on a person’s civil rights (specifically
the right to liberty, by confinement in a mental health facility) where there is
a significant risk of harm to the person or to the public due to the person’s
mental disorder (Nunnelly, 2016; Bhugra et al., 2017).
Canadian courts have ruled that people with decision-making capacity have the
right to refuse medical treatment, including the right to refuse life-sustaining
treatment. In Starson v. Swayze, which examined the right to refuse medical
treatment in an individual with a mental disorder, the Supreme Court of Canada
ruled that the “right to refuse unwanted medical treatment is fundamental to a
person’s dignity and autonomy. This right is equally important in the context of
treatment for a mental illness” (SCC, 2003). Thus, patients with mental disorders
who are judged to have capacity have the right to refuse treatment even where
the consequence of the refusal may be death or indefinite confinement in a
psychiatric institution.
Notwithstanding Starson v. Swayze, there is variability in provincial and territorial

approaches to whether an involuntarily hospitalized person can refuse treatment
for their mental disorder (Nunnelly, 2016; Wildeman, 2016; Chandler, 2017).
Treatment for purposes unrelated to the person’s mental disorder is subject
to the generally applicable laws regarding consent to treatment (Gilmour,
2017). In Ontario, a person with a mental disorder always has the right to
refuse treatment when they have decision-making capacity (Chandler, 2017).
However, such people can still be involuntarily hospitalized, and can continue to
be detained as long as they continue to meet criteria for detention. In contrast,
in British Columbia, people with a mental disorder who have been involuntarily
hospitalized have no right to refuse treatment. Instead, such patients are deemed
to consent to any treatment authorized by the director of the psychiatric care
facility.10 In Nova Scotia, Newfoundland, and Saskatchewan, incapacity is a
precondition for involuntary hospitalization; therefore, the issue of treatment
refusal by people with capacity who have been involuntarily hospitalized does not
arise. In Alberta and New Brunswick, a person with a mental disorder who has
decision-making capacity has the right to refuse treatment following involuntary
admission to a psychiatric facility, but this refusal can be overridden in certain
circumstances — for example, when it is judged to be in the person’s best
interests (Chandler, 2017; Gilmour, 2017). Finally, in Quebec, a person who
represents a danger to themselves or to others and who has been hospitalized
in a psychiatric facility cannot be treated against their will if they categorically
refuse treatment. However, if the person is incapable of giving consent and
categorically refuses to be treated even with the consent of an SDM, forced
treatment can be imposed with a court order (Deschamps, 2017b).
3.6.4 Conflicts in Laws and Jurisdiction

In the context of MAID MD-SUMC, potential tensions exist between federal
and provincial and territorial laws, and there may be issues of constitutional
jurisdiction and paramountcy in the context of enacting safeguards on the
practice of MAID MD-SUMC, were it more broadly permitted. Whereas the
federal government is responsible for Canada’s Criminal Code, which sets out
the legal conditions under which MAID can be provided, areas of mental health
law such as informed consent and capacity are normally considered matters
of provincial and territorial jurisdiction. These issues are relevant to some of
the safeguards discussed in Chapter 6.
3 .7 KN O W L E DGE GAP S
Data on mental disorders and mental healthcare in Canada are incomplete.

There are limited data on mental healthcare services delivered in the community
(MHCC, 2014a), despite the importance of community mental health treatment
in the management of mental disorders.
Given the existing inequalities in access to mental healthcare and social services
in Canada, it is unknown whether people who might request MAID MD-SUMC
have adequate access to mental healthcare and social services that could
potentially alleviate their suffering. Concerns have been raised by the Collège
des médecins du Québec about the possibility that patients might request
MAID in response to insufficient access to other end-of-life care (CMQ, 2018).
10 As of October 2018, there was a challenge to this law before the Supreme Court of British
Columbia (Woo, 2016).
There are almost no data on the demographic and socio-economic characteristics

of people requesting psychiatric EAS in other jurisdictions (beyond age and
gender). Therefore, it is difficult to hypothesize about the demographic and
socio-economic characteristics of people who may request MAID MD-SUMC
in Canada.
More research is required to clarify the relationship among the gender ratio
of mental disorders, the gender ratio of psychiatric EAS requests in Belgium
and the Netherlands, and the gender ratio in attempted suicide rates, in order
to determine whether women are disproportionately likely to seek assisted
dying for mental disorders, and if so, whether that is due to social inequalities.
Chapter 4 Mental Disorders and MAID — Key Issues 61
4
Mental Disorders and MAID — Key Issues
• Issues Regarding Current Eligibility Criteria
• Suicide and MAID MD-SUMC
• Vulnerability and Autonomy
• Mental Healthcare and Treatment
• Knowledge Gaps
4 Mental Disorders and MAID — Key Issues
Key Findings
Most people with a mental disorder as their sole underlying medical condition cannot
satisfy the current eligibility criteria for MAID, including several of the criteria for a
“grievous and irremediable medical condition” such as “natural death has become
reasonably foreseeable”(Section 4.1.2).
What it means to respect the autonomy of an individual with a mental disorder is

complex. Some believe that respect for autonomy requires non-interference in a
capable person’s decisions and self-determination. Others argue that respect for
autonomy requires consideration of a person’s social relationships and other resources
necessary for autonomous decision-making (Section 4.3.2).
Most people with mental disorders have the capacity to make treatment decisions,
but evidence shows that some mental disorders can impair decision-making and
increase the risk of incapacity. Capacity evaluations can vary in reliability and validity
depending on the population evaluated, the decisions involved, and the method of
evaluation (Section 4.1.1).
Suicide is a major public health concern. There is some evidence that some people
who have sought psychiatric euthanasia and assisted suicide in jurisdictions that
permit it share certain characteristics with people who attempt suicide. Working Group
members have different views about the relationship between MAID MD-SUMC and
suicide and whether it is possible to distinguish between them (Section 4.2).
The symptoms of some mental disorders can affect decision-making in significant

ways, including leading to a desire to die, hopelessness, and a negative view of the
future, even when a person retains decision-making capacity (Section 4.3.3).
As demonstrated in the previous chapter, the mental disorders landscape in

Canada is legally and medically complex, and its problematic history has had
especially negative impacts on marginalized people. Prohibiting or more broadly
permitting MAID MD-SUMC is a question that must be considered alongside
key issues such as eligibility criteria, including capacity to provide consent;
vulnerability and autonomy; the state of mental healthcare and treatment
in Canada; and the realities of suicide. This chapter addresses those issues in
relation to MAID MD-SUMC.
4 .1 I S S UE S RE GAR DI NG CU RR E NT ELIGIB ILITY C R ITER IA
People with a mental disorder as their sole underlying medical condition are
not explicitly excluded from access to MAID, but very few are likely to qualify
under the current eligibility criteria.
Bill C-14 — An Act to Amend the Criminal Code and to Make Related Amendments to
Other Acts (Medical Assistance in Dying) — establishes that a person may receive
MAID only if they meet all of the following eligibility criteria (GC, 2016b):
• “they are eligible […] for health services funded by a government in Canada;
• they are at least 18 years of age and capable of making decisions with respect
to their health;
• they have a grievous and irremediable medical condition;
• they have made a voluntary request for medical assistance in dying that, in
particular, was not made as a result of external pressure; and
• they give informed consent to receive medical assistance in dying after having
been informed of the means that are available to relieve their suffering,
including palliative care.”
The law defines a person as having a grievous and irremediable medical condition
by four factors, all of which need to be present (GC, 2016b):
• “they have a serious and incurable illness, disease or disability;
• they are in an advanced state of irreversible decline in capability;
• that illness, disease or disability or that state of decline causes them enduring
physical or psychological suffering that is intolerable to them and that cannot
be relieved under conditions that they consider acceptable; and
• their natural death has become reasonably foreseeable, taking into account
all of their medical circumstances, without a prognosis necessarily having
been made as to the specific length of time that they have remaining.”
Because mental disorders are diverse and heterogeneous, and because they
affect individuals in different ways, the implications of each eligibility criterion
will vary for different people. This variability is also linked to people’s individual
support networks. The course of a mental disorder and its impact on a person
is a complex interaction among the disorder, the individual, and their social
environment.
In its review of the evidence, the Working Group identified three main issues
associated with the current eligibility criteria that have particular implications
for MAID MD-SUMC in Canada:
1. Mental disorders may impair a person’s capacity to make decisions with
respect to their health and their ability to give informed consent to MAID.
2. Mental disorders may not satisfy all four criteria of a grievous and irremediable
medical condition as defined by Bill C-14.
3. A MAID MD-SUMC request may be less likely to be voluntary and more likely
to be the result of external pressure.
4.1.1 Capacity
To be eligible for MAID under Canadian law, a person must be able to provide
informed consent and be “capable of making decisions with respect to their
health” (GC, 2016b). The Department of Justice (2016) glossary for MAID (now
archived) further defines being “mentally competent or capable;”
A person is mentally competent or capable when they have the capacity

to understand the nature and consequences of their actions and choices,
including decisions related to medical care and treatments.
This is similar to the understand/appreciate test for capacity described in

Section 3.6.2. In Canada, people are presumed to have the capacity to make
decisions about their health unless there is sufficient evidence to the contrary
(Gov. of ON, 1996; Wildeman, 2016). The vast majority of people with mental
disorders are deemed to have capacity to make treatment decisions, but it is
accepted that mental disorders can affect a person’s decision-making.
The Impact of Mental Disorders on Decision-Making Capacity

Mental disorders can affect decision-making capacity in many ways.
In some instances (e.g., certain neurocognitive disorders like dementia,
neurodevelopmental disorders and intellectual disabilities, and some cases
of schizophrenia), there is a clear decline in the cognitive abilities needed to
understand and appreciate information. In other instances (e.g., depressive,
bipolar, and anxiety disorders), a person’s capacity for making decisions can be
impaired by the disorder’s impact on their mood and emotions. For example,
depression can impair one’s ability to deliberate about the future (Meynen,
2011; Halpern, 2012; Owen et al., 2013) or to maintain a minimal concern for
self (Elliot, 1997). Furthermore, some disorders, such as bipolar disorder, may
be characterized by manic, depressive, or mixed states, in which the impact of
emotion on capacity will vary.
Clinical symptoms and diagnoses may indicate impaired decision-making

capacity. However, by themselves, neither symptoms of a mental disorder nor
diagnoses on their own justify a designation of incapacity; a clinical assessment
of a patient’s decision-making abilities is always necessary (Kim, 2010; Candia
& Barba, 2011). Nevertheless, a systematic review of studies examining the
impact of mental disorders on decision-making capacity found that capacity
is more often impaired in people with psychotic disorders than in those with
non-psychotic disorders, and most (but not all) of the studies examined found
that the severity of psychopathology is associated with a loss of capacity (Okai
et al., 2007).
Specific symptoms have been linked with impairment of decision-making capacity

in certain disorders. For example, a 2009 study found hallucinations and poor
cognitive performance were more strongly associated with incapacity in non-
psychotic disorders (such as depression and personality disorder) compared
to psychotic disorders (such as schizophrenia) and bipolar disorder (Owen et
al., 2009a). In contrast, conceptual disorganization was associated with lack of
capacity in psychotic disorders and bipolar disorder, but not in non-psychotic
disorders (Owen et al., 2009a). Depressed mood was found to be strongly
associated with incapacity in patients with non-psychotic disorders. However, in
patients with psychotic disorders, depressed mood was more closely associated
with intact decision-making capacity (Owen et al., 2009a).
Owen et al. (2009a) and Cairns et al. (2005a) found that insight — measured
by the degree to which a person is aware of their mental disorder — was
the psychopathological variable most strongly associated with capacity. This
association was found to hold across all mental disorders examined in the studies,
although it was strongest in psychotic disorders and bipolar-affective disorder,
and weaker in non-psychotic disorders (in which severity of depressed mood
was more strongly associated with capacity status when compared to other types
of disorders) (Owen et al., 2009a). Although insight is not explicitly featured
as a criterion of capacity, it arguably can be considered to be subsumed under
the “appreciation” criterion of capacity tests (Spencer et al., 2017) used under
Canadian law and in clinical practice (Section 3.6.2). In addition, both Owen
et al. (2009a) and Cairns et al. (2005a) found that the presence of delusions
was associated with findings of incapacity. Elated mood was strongly associated
with lack of capacity in bipolar disorder (Owen et al., 2009a), as were mania and
hypomania for those with bipolar disorder and psychosis (Cairns et al., 2005b).
A systematic review of studies examining the impact of mental disorders on

decision-making capacity found that rates of incapacity in psychiatric inpatients
varied widely among studies; one study found that up to 50% of people admitted
voluntarily to an inpatient unit had significant impairment in capacity, while

another found 10 to 95% of people who were already inpatients lacked capacity
(Okai et al., 2007). A study by Cairns et al. (2005b) found that about 44% of
psychiatric inpatients lacked capacity to make treatment decisions, while Owen
et al. (2009a) reported that 58% of inpatients in their study lacked capacity.
However, these findings should be treated with caution, for a number of reasons.
First, they are based on studies conducted on psychiatric inpatients, who have
often either (i) been involuntarily hospitalized for their mental disorder, or
(ii) are undergoing voluntary hospitalization because they are in a state of crisis,
thereby likely skewing the findings towards a greater prevalence of incapacity.11
International evidence suggests that, if MAID MD-SUMC were more broadly
permitted in Canada, the majority of those requesting MAID MD-SUMC would
not be inpatients; a 2016 review of 66 case summaries of patients who received
psychiatric EAS in the Netherlands found that 24% of patients (16 of 66) were
institutionalized, and that 76% (50 of 66) were not institutionalized (Kim et al.,
2016). Second, these studies involved different contexts, treatment decisions,
and patient populations. Since capacity is always assessed relative to a particular
person, for a particular decision, and in a particular context, it is difficult to
extrapolate generalized conclusions from these data about the prevalence of
decisional capacity among people with mental disorders. Finally, none of the
above studies specifically examined decision-making capacity in the context of
a MAID MD-SUMC request. Most of them focused on an inpatient’s decision to
accept or refuse psychiatric treatment (e.g., taking medication), or their decision
about admission to the unit. As a matter of life and death, a MAID MD-SUMC
request involves a different set of considerations and therefore requires a high
threshold of capacity (this issue is discussed further in the following section).
Reliability and Accuracy of Capacity Assessments

The capacity of people with mental disorders to make decisions about their
health is assessed with or without the use of formal tools such as the MacArthur
Competence Assessment Tool (MacCAT) (Grisso et al., 1997) or Aid to Capacity
Evaluation (ACE) (Etchells et al., 1999).12 The evaluation of capacity is not
straightforward, even when formal tools are used, because these tools provide
data on a scale of a person’s abilities (such as the ability to understand and
appreciate information, to think and reason rationally, and to communicate
a stable choice), whereas the task of the evaluator is to generate a categorical
yes or no judgment about the patient’s capacity to make a particular decision
(Grisso et al., 1997; Kim, 2006; Appelbaum, 2007).
11 A systematic review found that patients who had been involuntarily hospitalized were more
likely to be found to lack capacity (Okai et al., 2007).
12 For a comprehensive list of different clinical capacity assessment tools, see Kim (2010).
There is conflicting evidence on the reliability of capacity assessments, as

measured by the degree of agreement among independent assessors. Part of
the reason for this conflict is because of differences in study design; different
studies assess the reliability of decision-making capacity in different contexts,
using different tools and methods, with different patient groups, and about
different decisions.
A 2007 systematic review of studies that examined the reliability of capacity

assessment found high rates of agreement among independent clinicians who
assessed capacity in psychiatric patients (Okai et al., 2007). Furthermore, some
studies reported that the MacCAT can be a useful instrument for helping to
reliably produce agreement among capacity assessors for psychiatric inpatients
(Cairns et al., 2005b), people with Alzheimer’s disease (Kim et al., 2001), and
people with schizophrenia (Kim et al., 2007).
Other studies found significant rates of disagreement among capacity assessors

(Marson et al., 1997; Kim, 2006). A 1997 study found that physicians with
experience assessing the decision-making capacity of dementia patients agreed
56% of the time on capacity assessments of people with mild Alzheimer’s disease
(Marson et al., 1997). Kim (2006) also found that rates of disagreement among
experienced capacity assessors changed based on the level of risk involved with
the proposed treatment: the higher the risk of the treatment, the higher the
rate of disagreement among assessors, and the more likely patients would be
assessed as lacking capacity.
It is not surprising that capacity assessments of the same person may vary
depending on the perceived risk of the intervention. Evaluation of capacity
is always made in relation to a specific decision, and different thresholds for
capacity are appropriate for different decisions and in different contexts,
taking into account the patient’s individual circumstances, such as diagnosis,
risks, benefits, and potential outcomes. As noted in Section 3.6, a person might
have the capacity to make some decisions but not others. As Kim (2010) puts
it, “it is widely accepted that the level of abilities required — the threshold for
competence — increases as the risk-to-benefit ratio increases.” In short, the
riskier the outcome, the higher the bar for capacity. This view is supported by
the Canadian Psychiatric Association (CPA, 2014).
Even if current capacity assessment procedures and instruments are reliable, it

does not mean they are valid. Reliability is the degree to which an assessment test
or tool produces stable and consistent results. But while a tool may be stable and
consistent, it may not be accurate. The validity of the capacity assessments — how
well they actually measure the capacity to make decisions — cannot be measured
by rates of agreement among capacity assessors. In other words, the fact

that a certain capacity assessment tool can produce high rates of agreement
among capacity assessors does not mean that tool is itself a valid way to measure
capacity. Reliability does not guarantee validity, although reliability is a necessary
condition for validity. For instance, a capacity assessment tool may reliably assess
some of the factors important for capacity, such as cognitive abilities, but not
sufficiently capture other factors, such as a person’s emotions or values with
respect to a particular decision (Charland et al., 2016). In addition, the validity of
the tool may vary depending on the type of decision being made — a particular
tool may be valid in some contexts or for some decisions, but inappropriate
and invalid in other contexts or for other decisions.
Finally, capacity is a complex concept that relies on both empirical and normative
considerations. Grisso (2003) concluded that a capacity evaluation must take
into account the causal component (the disorder causing impairment), the
functional component (such as understanding and appreciation), the interactive
component (a person’s abilities in relation to the demands of the context),
and a judgmental (or normative) component (which “invariably constitutes
a legal, moral, or social judgment”). There is no objectively correct answer
to the question of whether or not an individual really has capacity. Rather,
capacity is a socionormative construct — an evaluative standard that combines
objective information about the effects of mental disorders with societal values
about the kinds of abilities that a person ought to have in order to be allowed
to make certain kinds of decisions (Beauchamp & Childress, 2013). This, in
turn, determines how people may permissibly be treated.
Challenges in Assessing Decision-Making Capacity in

MAID MD-SUMC Cases
There is a unique challenge in assessing decision-making capacity for MAID
MD-SUMC in people with mental disorders: their desire to die could be a
symptom of their condition (Appelbaum, 2016). Although most people with
mental disorders do not want to die, suicidal ideation is a common symptom
of some mental disorders (e.g., major depressive disorder). Of course, a desire
to die may also reflect a person’s autonomous and well-considered decision to
end their life, even if they have a mental disorder. A desire to die in a person
with a mental disorder is not necessarily pathological or non-autonomous.
However, it may be difficult even for experienced clinicians to distinguish
between (i) an autonomous, well-considered decision to die in a person with
a mental disorder, and (ii) a pathological desire to die that is a symptom of
that person’s mental disorder. This challenge may also arise in cases where a
person with a mental disorder refuses or requests the removal of life-sustaining
medical treatment, which will result in their death (Downie & Dembo, 2016).
See Section 4.1.4 for further discussion of the similarities and differences
between MAID MD-SUMC and other highly consequential decisions.
Some experts have suggested that, in order to determine whether a patient’s

decision to die is a symptom of their mental disorder, assessments of capacity
must take into account not only the cognitive abilities but also the emotions,
values, and valuing abilities of the patient (Tan et al., 2006; Charland et al., 2016;
Kim, 2016). Some have argued that formal capacity assessment tools such as
the MacCAT focus only on cognitive abilities and do not sufficiently capture
a person’s emotions or values with respect to a particular decision, making
them inappropriate for assessing capacity in the context of MAID MD-SUMC
(Charland et al., 2016).
Clinicians may also assess the long-term stability of a person’s desire to die in
order to determine whether it is pathological. A desire to die that decreases as
the episode of the mental disorder responds to treatment is more likely to be
pathological, and less likely to be an autonomous, well-considered decision. The
trajectory of the desire to die is not included as a criterion of the understand/
appreciate test for decision-making capacity found in Canadian law; however,
stability of choice is part of the most widely used clinical model of capacity
(Appelbaum & Grisso, 1988). In the Netherlands, assessing the trajectory of the
desire to die is required when evaluating a request for EAS (Chapters 5 and 6).
4.1.2 Are some Mental Disorders “Grievous and

Irremediable” Conditions?
People requesting MAID MD-SUMC may not satisfy several of the four criteria
(listed in Section 4.1) of having a “grievous and irremediable medical condition”
(GC, 2016b). Clinicians disagree about when and which mental disorders can be
considered incurable. People with mental disorders can experience an advanced
state of decline in capabilities (especially in neurocognitive disorders such as
some dementias), but for some conditions it is not clear how often such declines
are irreversible. However, it is generally accepted that some mental disorders
can produce enduring and intolerable suffering. In the vast majority of cases
where a mental disorder is the sole underlying medical condition, a person’s
natural death has not become reasonably foreseeable (at least until the person
is at an advanced age). Each of these issues is discussed in detail below.
Incurability
In order to be eligible for MAID in Canada, a person must have a “serious and
incurable” condition (GC, 2016b). In medicine, there is no single, universally
agreed-upon definition of the term incurable. Stedman’s Medical Dictionary
defines cure as “[t]o heal; to make well” and “[a] restoration to health” (Stedman,
2006), but does not define the term incurable. Other major medical dictionaries
such as Webster’s New World Medical Dictionary do not define either term
(Shiel et al., 2009). The Oxford English Dictionary defines incurable as “cannot
be cured; incapable of being healed by medicine or medical skill” (OED, 1989).
Understood in strictly biological, reductionist terms, the term cured may

sometimes refer to a state in which an underlying pathophysiological process
has been eradicated (Moncrief, 2008). Since most mental disorders are usually
not defined in terms of underlying pathophysiology (Section 3.1.2), they
typically cannot be characterized as either curable or incurable going by this
understanding of the term.
Although in clinical practice the term incurable is not typically used to describe
most mental disorders, a variety of other possible definitions of incurability
can be found (e.g., in common or lay usage, or in the Canadian legal context),
and a mental disorder may be considered to be incurable based on one or
more of these other definitions. For example, mental disorders that persist are
considered to be chronic conditions (Ratnasingham et al., 2012; PHAC, 2015a;
Perring, 2018), and it is generally accepted that chronic conditions are usually
not curable. The focus of treatment for chronic mental disorders tends to be
management of symptoms, restoration of function, and decreasing the risk of
complications (such as suicide) and relapse of symptoms (Miller et al., 2006).
The risk of relapse is linked to the type of mental disorder and individual
vulnerability, but also often to the social context in which the person lives,
available supports, and possible treatments (Rickwood, 2006).
Another potential way to interpret incurability in the context of mental disorders

is in terms of treatment resistance — i.e., the absence of meaningful symptom
reduction following a certain number or type of interventions under appropriate
conditions. This term arises from a biological psychiatry perspective that focuses
on the success of pharmaceutical trials, and typically excludes psychological
interventions such as therapy (Anderson, 2018). However, treatment resistance is
also a problematic concept (see Section 3.1.2), and cannot be taken to indicate
that a person has no hope of future improvement. A person’s symptoms can
change over time, as can the impact of interventions. Moreover, treatment-
resistance specifically refers to a lack of reduction in the symptoms of a person’s
mental disorder, and not necessarily to the relief of their suffering or reduction
of their desire to die.
Even when a person’s mental disorder has been deemed treatment-resistant,

it does not necessarily mean there has been no improvement in the patient’s
condition. Symptom reduction is only one way of measuring clinical
improvement — a person’s functioning and their quality of life may only be
partially linked to symptom reduction. For people with mental disorders, quality
of life can also be linked to social determinants of health including stigma,
employment, education, housing, and social relationships (MHCC, 2012).
From this perspective, a person’s mental disorder might be considered to

be incurable when the goal of treatment cannot be achieved, which may or may
not include symptom reduction. For example, Hearing Voices Network does not
see the eradication of auditory hallucinations as the goal of treatment, but
rather learning to live well with the phenomenon (HVN, 2018). Similarly, the
recovery movement in mental health (Section 4.4) emphasizes living “a satisfying,
hopeful, and contributing life, even when there are ongoing limitations caused
by mental health problems and illnesses” (MHCC, 2012). However, proponents
of recovery-oriented practice also argue that the concept of recovery is not
synonymous with cure, and does not necessarily imply remission of symptoms
or a return to normal functioning (Anthony, 1993; Jacobson & Greenley, 2001;
Davidson & O’Connell, 2005; Davidson & Roe, 2007; MHCC, 2012). In this
view, regardless of whether the symptoms are alleviated, a person might be
unable to recover from their mental disorder due to ongoing social hardships
such as stigma, unstable housing, or financial precariousness.
Incurability in the context of mental disorders may also relate to the acceptability
of treatment. Some argue that, if a person’s symptoms cannot be reduced or
eradicated by a treatment that is acceptable to them, their condition should
be considered incurable, even if an effective treatment is available (Downie &
Chandler, 2018). According to this view, if a person has an infection that could
be treated with an antibiotic, but refuses the medication on the grounds that
it is not acceptable to them, their condition could be considered incurable.
Similarly, a person’s mental disorder might be considered incurable on this
view if the available treatments are unacceptable to them.
In the context of mental disorders, treatment success (or failure) is often

evaluated in terms of functional improvement, symptom reduction, or
improvement in quality of life, rather than in terms of curability. For many
people with mental disorders, effective treatment can profoundly improve quality
of life (Ratnasingham et al., 2012). A variety of terms are used to categorize
treatment outcomes of mental disorders (Box 4.1). In the view of some Working

Group members, the most relevant issue with respect to incurability and MAID
MD-SUMC is not whether treatment can cure a person’s mental disorder, but
whether it can alleviate suffering and reduce the symptoms that are motivating
their request for MAID. See Section 4.4 for more information on treatment
of mental disorders.
Box 4.1
Selected Mental Disorder Treatment Outcome Definitions
Episode
“the period during which an individual meets full symptomatic criteria for the disorder”
Remission
“the interim period (e.g., 2 weeks to 6 months) during which the individual’s symptoms
have decreased sufficiently that he or she has only minimal symptoms and no longer
meets full diagnostic criteria”
Partial Remission
“a period of decline from the episode to full remission”
Response (to treatment)

“the point at which partial remission begins”
Recovery (from the episode, not necessarily the illness)*

“when an individual remains minimally symptomatic beyond the defined period of
remission (e.g., more than 6 months)”
Relapse
“when symptoms meeting full diagnostic criteria reappear during the period of
remission (but before recovery)”
Recurrence
“the reappearance of a new episode once recovered”
(Bruce & Raue, 2013)
*This meaning of the term recovery should not be conflated with its meaning in the phrase recovery-
oriented practice.
Despite the debate about incurability described above, there is some consensus
in the literature that some mental disorders are currently incurable, such as
neurocognitive disorders like dementia associated with Alzheimer’s disease
(Jennekens, 2014). In addition, some argue that certain psychiatric conditions
such as depression can be considered potentially incurable since some people
with the condition do not respond to multiple treatments (Downie & Dembo,
2016). Others argue that “it is essentially impossible to describe any psychiatric
illness as incurable, with the exception of advanced brain damage as occurs
in progressive neurodegenerative disorders such as Alzheimer’s disease and
Huntington’s disease” (Kelly & McLoughlin, 2002), given the continuing
evolution of mental health research and the challenges associated with predicting
changes as a result of treatment or whether a patient’s condition will undergo
remission (Walker-Renshaw et al., 2015).
In summary, a variety of interpretations of incurability exist with respect to

mental disorders. Under some interpretations, a person’s mental disorder may
be considered to be incurable; using other interpretations, the mental disorder
may be considered curable (or cured); and using still other interpretations,
the concept of (in)curability simply does not apply to most mental disorders
in the first place.
Regardless of which definition of incurability is adopted, there may be further

questions about whether clinicians can reliably determine if a particular person
with a mental disorder meets that definition, thus adding a further layer of
complexity to the use of the term incurable in the context of mental disorders.
As discussed in Section 3.1.2, it can be difficult to determine with any degree
of certainty how a person’s mental disorder will evolve over time (prognosis),
and to what extent attempts to treat the condition will relieve the person’s
suffering and/or desire to end their lives, or improve their quality of life
(treatment effectiveness).
Advanced State of Irreversible Decline in Capability

In order to be eligible for MAID in Canada, a person must be “in an advanced
state of irreversible decline in capability” (GC, 2016b).13 There is some uncertainty
about the precise meaning of this criterion. First, it is not clear whether an
“irreversible” decline means that the condition (i) “cannot be reversed by any
means,” or that it (ii) “cannot be reversed by means available and acceptable to the
patient,” as with the requirement for intolerable suffering (Downie & Dembo,
13 Despite their terminological similarity, the term capability should not be conflated with capacity.
Whereas capacity specifically refers to a patient’s ability to understand and appreciate information
for the purposes of providing consent to treatment (Sections 3.6 and 4.1), capability refers to
general abilities and functioning.
2016, emphasis added). Second, it is not clear whether a decline in capability

must occur over a period of time, or whether a sudden decline would also
qualify (Downie & Chandler, 2018). Finally, it is unclear what this eligibility
criterion includes — as Downie and Dembo (2016) put it, “capability to do
what?” A person may irreversibly lose the capability to see due to progressive
macular degeneration, or lose the capability to regulate their blood sugar
due to adult-onset diabetes (Downie & Dembo, 2016). However, it is not clear
whether such conditions would meet this criterion.
People with mental disorders can experience declines in capability, both mental
and physical. People with a severe mental disorder score lower on measures
of physical functioning than the general population. For example, in one
study, people with mental disorders in residential care in their 40s had levels
of physical functioning that were comparable to “the elderly” (Chafetz et al.,
2006). Declines in capability may result directly from the symptoms of the
mental disorder itself, or may result from indirect factors related to the mental
disorder, such as co-morbid physical disorder(s), socio-economic hardship,
social isolation, homelessness, and addiction. MAID law in Canada does not
state that the decline must result from the condition itself.
A mental disorder may directly lead to physical and mental decline. For example,
eating disorders such as anorexia nervosa can result in severe malnutrition,
leading to organ failure, premature osteoporosis, and cognitive declines that
may be irreversible in some cases (APA, 2013). In some cases of schizophrenia
there is a clear decline in cognitive abilities (APA, 2013). Neurocognitive mental
disorders such as dementia due to Alzheimer’s disease can lead to an advanced
state of irreversible decline in capability, even before such conditions result in
the loss of a patient’s decision-making capacity.
In addition, some Working Group members believe that a mental disorder may
indirectly lead to a state of decline due to the effects of the disorder on a person’s
social situation, including isolation, inability to engage in social relationships,
homelessness, inability to access educational and employment opportunities,
and lack of self-care (Downie & Dembo, 2016). In the view of these Working
Groups members, these social factors can exacerbate a person’s mental disorder,
contribute to a decline in capability, and may be considered irreversible. For
some people with mental disorders, social supports and interventions may be
ineffective at mitigating their social problems, or may not be acceptable to the
person. For example, a 2015 study of housing interventions for people with
mental disorders in five Canadian cities found that 27% of participants were no
longer in stable housing within one year of the intervention, which included
rent supplements, assistance to find housing, and assertive community treatment
(Aubry et al., 2015). However, other Working Group members disagree that a
state of decline caused or exacerbated by the social hardships associated with
mental disorders should satisfy the “advanced state of irreversible decline in
capability” criterion, and disagree that such declines should be considered
irreversible.
Finally, some Working Group members believe that a mental disorder may lead
to an irreversible state of decline because the person may not seek help for
other undetected co-morbid physical disorders. As explained by Downie and
Dembo (2016): “Individuals with severe persistent mental illness (SPMI) may
cease to seek medical attention” and they may not participate in preventative
health care, leading to a higher risk that serious illnesses will not be detected
(Stern et al., 2016 as referenced in Downie & Dembo, 2016). Again however,
other Working Group members disagree that such declines should satisfy the
“advanced state of irreversible decline in capability” criterion.
Suffering
To be eligible for MAID in Canada, a person must have an “illness, disease
or disability or [...] state of decline [that] causes them enduring physical or
psychological suffering that is intolerable to them and that cannot be relieved
under conditions that they consider acceptable” (GC, 2016b). Mental disorders
can cause severe, enduring, and intolerable suffering. However, the concept
of suffering can be difficult to understand in the context of mental disorders.
Several definitions of suffering in the literature share common elements: suffering

is distinct from pain or physical distress, is not a symptom itself (unlike fear or
pain), and results from the meaning that a person gives their lived experience
(Cassell, 1982, 1991; Dees et al., 2009; Svenaeus, 2014; Gupta et al., 2017). As
Gupta et al. (2017) note, “suffering is an interpretation of experience, not a
sum of symptoms.” An influential definition of suffering comes from Cassell
(1982), who defined suffering as “the state of severe distress associated with
events that threaten the intactness of the person.” In this way, suffering is
closely related to personhood, and occurs when different aspects of a person are
threatened, damaged, or lost. Through an integrative literature review, Dees
et al. (2009) found that suffering in the context of requests for assisted dying
is related to “factors undermining the quality of life and by the perceived loss
of meaning and purpose in life.”
Under Canadian law, both physical and psychological suffering can qualify a
person for MAID (GC, 2016b). Belgium and Luxembourg also identify both
physical and psychological suffering as qualifying a person for EAS (Gov. of
Belgium, 2002; Gov. of Luxembourg, 2009). However, it has been argued that
categorizing suffering in this way may be inappropriate, unnecessary, and/
or impractical (Svenaeus, 2014; Gupta et al., 2017). A physical symptom can
become psychologically unbearable if a patient believes it will not lessen through
time, or if they are afraid it will worsen; suffering is both physical (pain) and
psychological (beliefs, fears) (Gupta et al., 2017). Moreover, mental disorders
can cause physical pain and suffering, as in the case of conversion disorder.
The Netherlands does not distinguish physical and psychological suffering in
their assisted dying law (Gov. of the Netherlands, 2002).
Intolerable Suffering
In order to be eligible for MAID in Canada, a person must experience suffering
that is “intolerable” to them (GC, 2016b). Similarly, in Belgium, the Netherlands,
and Luxembourg (the Benelux countries), people must experience “unbearable”
suffering to qualify for EAS.
A qualitative study of 26 requests for psychiatric EAS in Belgium by Verhofstadt

et al. (2017) analyzed patients’ descriptions of their unbearable suffering. The
study found that the unbearable suffering experienced by these people included
a wide variety of factors beyond the symptoms of their mental disorders alone,
and identified five broad categories of suffering — medical, intrapersonal,
interpersonal, societal, and existential — all of which contributed to the
unbearability of their suffering. In the medical domain, the study found that, in
addition to their psychological symptoms, patients also suffered due to physical
and psychosomatic symptoms, although mental suffering was experienced as
more disruptive than physical suffering. The study also found that patients
experienced suffering from issues related to treatment of their disorder, and
that the act of applying for EAS could also contribute to a patient’s suffering. In
the intrapersonal domain, a history of traumatic experiences and self-destructive
thoughts was found to contribute to patients’ suffering; in the interpersonal
domain, a lack of social support and understanding contributed to their suffering,
as did conflicts with important people in their lives and bereavement. In the
societal domain, social hardships, social isolation, and a lack of socio-economic
resources were found to contribute to suffering. Finally, the study found that
patients’ suffering became existential when they perceived their situation as
futile, with no prospect of improvement (Verhofstadt et al., 2017).
The Verhofstadt et al. (2017) study confirmed an earlier finding by Dees et al.
(2011) that psychiatric patients may suffer continuously. A literature review of
descriptions of suffering associated with requests for assisted dying found that
psychological symptoms, most notably hopelessness, were important factors
contributing to the intolerability of suffering (Dees et al., 2009). Furthermore,
the study found that, although medical and social factors both caused and
contributed to suffering, it was primarily the presence of psychological, emotional,
and existential problems that caused suffering to become intolerable (Dees et
al., 2009). In a follow-up qualitative study of 31 patients who requested EAS,
Dees et al. (2011) identified physical suffering as less important, and found that
those who emphasized continuous feelings of intolerable suffering had depression
(2 patients). However, it is important to note that the majority of the studies
reviewed by Dees et al. (2009) included only cancer patients, not patients with
a mental disorder as their sole underlying medical condition, although four
of the patients in Dees et al. (2011) identified a diagnosed psychiatric disorder
as motivating their requests for EAS.
Importantly, the tolerability of suffering is also highly individual. Dees et al. (2009)
found that the tolerability of suffering was the result of a complex interaction of
the person’s life history, symptoms, personality, social situation, and “existential
motivations,” and emphasized that “unbearable suffering […] in the context
of a request for EAS must do justice to the uniqueness of the individual who
makes the request” (Dees et al., 2009). Likewise, as the Netherlands’ Regional
Euthanasia Review Committees (RTE) Code of Practice points out:
What is bearable for one patient may be unbearable for another. This
depends on the individual patient’s perception of his situation, his life
history and medical history, personality, values and physical and mental
stamina. It is therefore important to consider the patient’s ‘biography’
when assessing his suffering.
(RTE, 2015b)
The type, severity, and pervasiveness of psychiatric symptoms can vary widely
from person to person, as can the effect of these symptoms on someone’s distress
and ability to function. One individual may experience many symptoms of a
mental disorder but still function well in their personal and social relationships,
despite suffering because of their disorder. A different individual with the
same disorder might function poorly in their personal and social relationships,
yet not suffer due to their disorder. And yet a third individual with the same
disorder may experience minimal symptoms but find these to be severely

debilitating, thus impairing their ability to function (Bruce & Raue, 2013). In
order to assess a patient’s suffering, healthcare practitioners must understand
the person as a whole, taking into account personality characteristics such as
values, roles, relationships (Gupta et al., 2017), biographical attributes, and
the “patient’s perspectives of the past, the present, and expectations of the
future” (Dees et al., 2011).
Evaluating a Patient’s Suffering

As with evaluations of capacity (Section 4.1.1), assessments of a patient’s suffering
may differ among evaluators, since healthcare practitioners do not necessarily
share the same values and experiences, and may therefore have different
interpretations of a patient’s experiences (and suffering) (Gupta et al., 2017).
It has been proposed that good clinical practice may direct a practitioner to
explore (rather than evaluate) a patient’s suffering, considering a patient’s own
account first, the observations of the people around them (family, friends, other
healthcare practitioners), and the current clinical snapshot (e.g., treatment
history, prognosis, treatment options going forward) (Gupta et al., 2017).
Typically, a clinical assessment of a patient’s suffering is undertaken in order

to know whether (and how) it can be relieved through treatment. However,
in a MAID context, where “intolerable suffering” is an eligibility criterion,
assessments of suffering are more complex. MAID law in Canada explicitly defines
intolerable suffering in subjective terms — i.e., “suffering that is intolerable to
them and that cannot be relieved under conditions that they consider acceptable”
(GC, 2016b, emphasis added). While a healthcare practitioner must “be of the
opinion that” these conditions are met, if a patient truly believes their suffering
is intolerable, and believes that existing means to relieve their suffering are
not acceptable to them, they thereby meet the criteria for intolerable suffering
set out in the legislation. However, the healthcare practitioner’s role remains
important even with respect to this subjective element of Bill C-14, as they
must determine whether there is any way of relieving a patient’s suffering that
is acceptable to that patient.
Some Working Group members believe that defining the relievability of suffering
solely in terms of subjective acceptability to the patient (as Canadian MAID law
currently does) would allow a person with capacity, whose decision is nonetheless
coloured by symptoms of their mental disorder, to reject a reasonable and effective
treatment, even if the treatment itself does not cause them additional suffering.
Distorted perceptions of intolerability and irremediability (i.e., the belief that
nothing can ever make a person feel any better) are common symptoms in
some psychiatric patients (such as those with personality disorders or major
depression, or those whose coping capacity is under stress) (MacLeod et al., 2004;
Halpern, 2012); these perceptions could change. Indeed, modern cognitive
behavioural therapies are designed to address just such distorted perceptions,
based on the idea that important therapeutic effects can result from helping
a person to become aware of the ways in which automatic thoughts shape and
distort their emotions and perceptions, and reframing those thoughts to reduce
their suffering (Wenzel et al., 2009; Beck & Beck, 2011). It may therefore be
difficult for a clinician to determine the permanence of a patient’s suffering
given the possibility of remission and/or a change in the patient’s distorted
perceptions. This points to a special vulnerability of people with mental disorders
in the context of MAID MD-SUMC: there will be situations in which a patient’s
perception of their intolerable suffering could be addressed clinically despite
their view that it is irremediable. Compared to Canada, assisted dying laws in
Belgium and the Netherlands contain a more objective definition of treatment
futility, wherein the patient and physician must together determine whether or
not there is no alternative to EAS — i.e., whether there are acceptable means
by which the patient’s suffering can be relieved (Gov. of Belgium, 2002; Gov.
of the Netherlands, 2002). See Section 5.6 for further discussion.
Reasonable Foreseeability of a Natural Death

In order for a person to be eligible for MAID in Canada, their “natural death
[must have become] reasonably foreseeable, taking into account all of their
medical circumstances, without a prognosis necessarily having been made as
to the specific length of time that they have remaining” (GC, 2016b). This
requirement would likely disqualify most people from eligibility in cases where
a mental disorder is their sole underlying medical condition.
There are some mental disorders for which the natural death of a person with
that disorder may be reasonably foreseeable, including certain neurodegenerative
conditions (such as dementia caused by Alzheimer’s disease) and some other
psychiatric conditions (such as anorexia). In addition, once a person is sufficiently
old, they may satisfy the “reasonably foreseeable” criterion due to age. Downie
and Chandler (2018) have suggested that Kay Carter would have qualified
on this basis (she was 89 years old and did not have a terminal condition; see
Section 2.1.4), and in 2017 the Ontario Superior Court of Justice ruled that a
77-year-old woman met the “reasonably foreseeable” criterion on the basis of
her age and health, despite not having a terminal condition (ONSC, 2017).
In addition, the Attorney General of Canada has stated that age is a factor to
consider when determining the reasonable foreseeability of a person’s death
in the context of MAID (Standing Committee on Justice and Human Rights,
2016a).
Although having a mental disorder is among the most important risk factors
for suicide, the increased risk of suicide in people with mental disorders is
not relevant to the “reasonably foreseeable” criterion because the current
legislation specifically requires that the person’s natural death has become
reasonably foreseeable, and suicide is not considered to be a natural death.
Suicide in the context of MAID MD-SUMC is discussed further in Section 4.2.
4.1.3 Voluntariness
Canadian MAID law requires that a person make “a voluntary request for
medical assistance in dying that, in particular, was not made as a result of
external pressure” (GC, 2016b). Given the history of stigma and discrimination
against people with mental disorders (Chapter 3), there may be concerns
that (i) someone’s decision to seek MAID might be due to stigma or the
perception that people with mental disorders are burdens on families, and/or
that (ii) families may pressure a person with a mental disorder to seek MAID.
According to the Derde evaluatie Wet toetsing levensbeëindiging op verzoek en hulp
(Third Review of the Dutch Act), in which psychiatrists evaluating patients
for EAS in the Netherlands were asked detailed questions about the last time
they had refused a request, respondents felt that “the patient was making the
request under the pressure of those close to him or her” in 5 of 66 (8%) cases
(Onwuteaka-Philipsen et al., 2017).14 Notably, psychiatrists also felt that they
were pressured “by those close to the patient to refuse the request” in 5 of 66
(8%) cases.15
4.1.4 Assessing Capacity and Prognosis: Comparing MAID MD-SUMC

to Other Highly Consequential Decisions
It can often be challenging to assess capacity and prognosis in some people with
a mental disorder. This can be a particular concern in the context of highly
consequential decisions that will lead to a patient’s death, such as MAID. This
section examines the similarities and differences between assessing a patient’s
capacity and prognosis (i) in the context of MAID MD-SUMC, versus (ii) in the
context of other highly consequential decisions that will lead to a patient’s death,
such as refusing life-sustaining medical treatment or MAID MD-SUMC where a
person is already eligible under the current law. Working Group members do not
agree about whether (and how) these situations differed, about whether MAID
MD-SUMC is novel and/or unique with respect to assessments of capacity and
prognosis, nor about whether existing practices in such situations could inform
the practice of MAID MD-SUMC in Canada, were it permitted more broadly.
14 Unofficial translation.
Some of these disagreements are related to the ethical and practical distinction
(or lack thereof) between acts and omissions (i.e., between killing and letting
die), as well as the ethical and practical significance (or lack thereof) of the
reasonable foreseeability of a person’s death. Some Working Group members
believe that there is a crucial ethical distinction between: (i) a healthcare
practitioner respecting the boundaries of a patient’s body and respecting a
competent patient’s treatment refusal, leading to the patient’s death due to
an underlying disease process, and (ii) a healthcare practitioner injecting a
lethal medication to end the life of a patient who is not dying. Other Working
Group members, however, reject the argument that there is a morally significant
distinction between acts and omissions that justifies a different approach
to MAID MD-SUMC, and point out that with Bill C-14, Canadian law has
accepted that active assistance in ending a person’s life is acceptable in at
least some circumstances. They also note that capable people with stable but
serious conditions (e.g., kidney failure) are permitted to refuse life-sustaining
treatment, despite their potential for a long life, even in circumstances where
they have a mental disorder.
Capacity
Some Working Group members point out that capacity assessments for people
with mental disorders must already be undertaken for certain highly consequential
decisions that could result in death, such as refusing life-sustaining treatment
(e.g., dialysis) or in MAID MD-SUMC cases where a person is eligible under the
current law (e.g., cases involving older people). In the view of these Working
Group members, it is not clear whether the complexity or challenges of assessing
capacity in these contexts is any greater than in other MAID MD-SUMC contexts.
Other Working Group members believe that such situations are extremely rare
and, as such, there are no existing capacity evaluation practices that could be
transferred over to MAID MD-SUMC, were it more broadly permitted.
If MAID MD-SUMC were more broadly permitted, the potential number of cases
in which capacity assessments must be made for highly consequential decisions
would increase, along with the frequency of potential errors both ways (i.e.,
assessing capable patients as lacking capacity, and assessing incapable patients
as having capacity). That said, some Working Group members note that Dutch
assessors who evaluated the decision-making capacity of people who requested
psychiatric EAS agreed with one another in most cases; disagreements about
whether the patient had the capacity to consent to EAS occurred in 12% (8 of
66) of cases (Doernberg et al., 2016) (see Section 5.6 for further discussion).
Other Working Group members believe that this finding must be contextualized
within Dutch practice and note that the same study also found that these
disagreements occur despite the fact that, in the view of Doernberg et al. (2016)
and these Working Group members, the thresholds used for capacity in the
Dutch practice of psychiatric EAS are not high.
Prognosis
For some patients with a mental disorder, it can be challenging to predict the
natural course of the disease and the effectiveness of treatment. For example,
a patient with depression may refuse life-saving medical treatment (e.g., kidney
dialysis), and there may be good information and high certainty about the
prognosis relating to the underlying physical condition (e.g., kidney failure),
but less information and lower certainty in relation to the prognosis relating
to their mental disorder.
In such cases, a patient may refuse medically necessary treatment in order to

escape the symptoms of the mental disorder and end their suffering. Some
Working Group members believe that, even in such cases, prognostic uncertainty
about the patient’s mental disorder (i.e., not knowing whether their depression
will improve or not) is not a valid reason for overriding a capable patient’s
refusal of treatment (although incapacity would be a valid reason to do so).
Other Working Group members believe that, although refusal of life-sustaining

dialysis does sometimes occur in patients with mental disorders, the above
example is not analogous to a MAID MD-SUMC situation. They believe that in
order for the analogy to apply to MAID MD-SUMC, the person with a mental
disorder should have a physical disorder that is fatal but trivial to treat, rather
than one that requires a burdensome treatment such as dialysis — for example,
a person with depression who has an infection that can be easily treated by
simply taking an antibiotic and which would be fatal without treatment. In
the view of these Working Group members, it is not clear that there is an
established practice regarding such situations from which inferences can be
drawn. They believe that, given that the patient refusing the antibiotic is known
to be depressed, current practice would likely be an assessment of suicidality.
Moreover, they believe that, even if a capacity evaluation became relevant,
such a case would most likely need to be adjudicated, and that no general
inferences can therefore be drawn regarding MAID MD-SUMC. In contrast,
other Working Group members believe that, if found to have capacity, such a
person would be entitled to refuse treatment, even if it resulted in their death.
Incurability and Relief of Suffering

In Canada, current eligibility criteria for MAID require that a patient’s condition
be incurable and that their suffering cannot be relieved under conditions that
they deem acceptable (GC, 2016b). Since those with a mental disorder as their
sole underlying medical condition are not excluded from MAID eligibility, some
Working Group members point out that clinicians are already required to assess
incurability and non-relievability of suffering in patients who are seeking MAID
MD-SUMC and whose natural death has become reasonably foreseeable — for
example, in the case of an older patient with major depression. In 2017,
the Ontario Superior Court of Justice ruled that a 77-year-old woman (without
a mental disorder) met the “reasonably foreseeable” criterion on the basis of
her age and health, despite not having a terminal condition (ONSC, 2017).
In addition, the Attorney General of Canada has stated that age is a factor to
consider when determining the reasonable foreseeability of a person’s death
in the context of MAID (Standing Committee on Justice and Human Rights,
2016a) (Section 4.1.2).
However, other Working Group members believe that even if such assessments
might be currently required in principle, they are not currently undertaken in
practice. According to these Working Group members, the example of the older
depressed patient is too speculative to be helpful, given that, to date, there have
been no such reported cases (in the Ontario case described above, the patient
did not have a mental disorder). Further, they believe that the supposition
that older patients could meet the “reasonably foreseeable death” criterion
on the basis of their advanced age is an evolving legal matter that has not
been addressed by the Supreme Court of Canada or in federal, or provincial
or territorial legislation, and as such, is not settled law. Thus, they believe
there are no currently existing practices or inferences that could be applied
to MAID MD-SUMC, and that, at most, the Ontario example demonstrates
that situations requiring eligibility decisions based on uncertain prognoses
may already be occurring.
If MAID MD-SUMC were made more broadly available, there would be an

increase in the potential number of cases in which these challenging prognostic
decisions must be made, along with the frequency of potential errors. However,
some Working Group members point out that — as discussed further in
Section 5.6 — the available evidence suggests that Dutch assessors agreed about
treatment futility (i.e., incurability and non-relievability of suffering) in the
majority of psychiatric EAS cases; disagreements occurred in 20% (13 of 66) of
cases (Kim et al., 2016). Other Working Group members believe that differences
between the Dutch and Canadian assisted dying laws must be taken into account
when discussing this finding. Specifically, the Dutch law requires that both
the patient and the physician must together agree there are no reasonable
treatment options before EAS can be accessed, which arguably provides an
objective criterion for treatment futility. In contrast, Canadian MAID law is
based on a patient’s subjective views of what constitutes “acceptable treatment,”
and does not require that the patient attempt any available treatments for the
purposes of MAID eligibility.
4 . 2 S UI C I D E A N D M AI D M D-S U M C
The preamble to Bill C-14 includes several statements that are relevant to an
analysis of the relationship between suicide and MAID MD-SUMC:
• Whereas the Parliament of Canada recognizes the autonomy of persons
who have a grievous and irremediable medical condition that causes them
enduring and intolerable suffering and who wish to seek medical assistance
in dying; […]
• Whereas it is important to affirm the inherent and equal value of every
person’s life and to avoid encouraging negative perceptions of the quality of life
of persons who are elderly, ill or disabled;
• Whereas vulnerable persons must be protected from being induced, in moments of
weakness, to end their lives;
• Whereas suicide is a significant public health issue that can have lasting and harmful
effects on individuals, families and communities;
• Whereas, in light of the above considerations, permitting access to medical
assistance in dying for competent adults whose deaths are reasonably
foreseeable strikes the most appropriate balance between the autonomy of
persons who seek medical assistance in dying, on one hand, and the interests
of vulnerable persons in need of protection and those of society, on the other.
(GC, 2016b, emphasis added)
MAID currently allows a person to end their suffering by accelerating the

timing and manner of their reasonably foreseeable death. Under the current
law, self-administered MAID is considered to be a form of suicide — aiding
self-administered MAID is an exception to the Criminal Code’s prohibition on
assisting suicide (GC, 2016b). In most cases of MAID MD-SUMC, death would
generally occur when the person’s natural death has not yet become reasonably
foreseeable, as is the case for most people who die by suicide. Expanding
MAID MD-SUMC means determining whether it is ethical to assist people with
mental disorders whose natural death is not reasonably foreseeable to end
their lives, considering the association between suicide and mental disorders
(Section 3.2). And even if such acts are ethical, there remains the question of
whether is it possible to reliably identify those suicides that society wishes to
assist and those it wishes to prevent. This section explores the Working Group’s
divergent views on why society tries to prevent suicide, and whether suicide can
be differentiated from MAID MD-SUMC. Chapter 6 includes a discussion of
the implications of prohibiting or more broadly permitting MAID MD-SUMC
related to suicide, as well as an examination of related safeguards.
4.2.1 Why Does Society Seek to Prevent Suicide?

Suicide is identified as a significant public health issue in the preamble to Bill
C-14 (see above). Additionally, An Act Respecting a Federal Framework for Suicide
Prevention became law in December 2012, and the resulting framework’s stated
vision is “a Canada where suicide is prevented and everyone lives with hope
and resilience” (GC, 2016c). Both the framework and Bill C-14 emphasize that
suicide can have lasting and harmful effects.
Working Group members had different perspectives on what suicide prevention

information should be presented in this report. This is not surprising given the
range of disciplinary and experience-informed perspectives among Working
Group members. Two perspectives are presented here.
One Perspective
In the view of some Working Group members, society’s justifications for seeking
to prevent suicide can include: (1) beliefs about the value of life (whether these
are religiously-based or secular); (2) religious views that God, not humans must
decide the timing of death; (3) arguments that suicide causes harm to people
apart from the one who dies (e.g., family members), society or both; and/or
(4) concerns that suicide is non-autonomous (Cholbi, 2017). These Working
Group members acknowledge that some scholars argue the primary justifications
to prevent suicide are: (i) based on the observation that the majority of people
whose suicides are prevented are grateful for having been stopped (or saved)
from completing suicide; and (ii) in some instances of suicide, harm is done to
the individual (see Another Perspective below). These Working Group members
believe that (i) maps onto justification (4) (autonomy) and (ii) maps on to
justification (1) (value of life), respectively.
An Act Respecting the Federal Framework for Suicide Prevention notes that “[p]eople
experiencing thoughts of suicide or suicide-related behaviour may feel hopeless
or overwhelmed and see no other option” (GC, 2016c). Embedded within this
statement is the idea that suicide is not a true reflection of what such people
want, and that their appraisal of their situation may be mistaken or distorted.
If offered appropriate help, they could potentially find solutions for the
problems that led them to feel hopeless or overwhelmed. Thus, in the view of
these Working Group members, such thoughts of suicide or suicide-related
behaviour are in some sense non-autonomous (Section 4.3.2), and this lack of
autonomy could be further understood in at least two different ways:
• Incapacity: As discussed in Section 4.1.1, while the majority of people with

mental disorders have decision-making capacity, in some cases the symptoms
of mental disorders can compromise decision-making. A person may make
a decision to attempt suicide when they lack the capacity to understand and
appreciate the consequences of that decision. For example, a person with a
psychotic disorder might hold a delusional belief that if they were to die by
suicide, they would save the world.
• Authenticity: As discussed in Sections 4.1.1 and 4.3.2, the desire to die in

people with mental disorders may be a symptom of their disorder rather
than a choice based on their values and beliefs. That is, even if such people
fulfil the legal criteria for decision-making capacity, their expressed desire
to die is inconsistent with their non-disorder-related values, goals, and/or
life history. In short, the concern is that the person does not really want to
die. For example, prior to the onset of a major depressive episode, a person
may have always been goal-oriented and resilient. Now, as a result of the
impact of depression on their thinking, they believe that they can never
accomplish their goals, feel hopeless, and see no purpose in living. There are
philosophical and legal disagreements about the existence and/or relevance
of authenticity to decision-making.
Additionally, as stated above, the preamble to Bill C-14 expresses concern for
those who might end their lives “in moments of weakness” (GC, 2016b). In the
view of these Working Group members, two characteristics of suicidality that
might be relevant to such moments of weakness are ambivalence (Section 3.2)
and impulsivity:
• Ambivalence: The same Working Group members believe there are at least
two ways in which ambivalence can be understood in the context of suicide
prevention: (i) when a person fully changes their mind (i.e., is confident they
want to attempt suicide at one time and is confident they do not want to at
another time); (ii) when a person is of two minds at once (i.e., both wants
to attempt suicide and does not want to at the same time or, put differently,
simultaneously wants to live and wants to die). For example, a person might
attempt suicide while experiencing a desire to die, but, had they waited
or received some form of suicide prevention intervention (or had their
circumstances otherwise changed in material ways), they would have changed
their mind and no longer desired to die. Another possibility is that, on balance,
the person wanted to die, but, had they waited or received treatment (or
had their circumstances otherwise changed in material ways), the balance
between their competing desires would have shifted and, on balance, they
would have wanted to live. As discussed in Section 3.2, ambivalence about
dying is considered to be a characteristic of the desire to kill oneself.
• Impulsivity: The importance of impulsivity in the context of MAID is illustrated

in the preamble to Bill C-14 (“Whereas vulnerable persons must be protected
from being induced, in moments of weakness, to end their lives” (GC, 2016b)).
The concern expressed here is that a person might attempt suicide suddenly
and without careful thought and, had they waited or thought more carefully,
they would no longer have desired to end their lives. The extent to which
impulsivity is involved in suicide is a matter of debate. For example, Anestis
et al. (2014) concluded that the role of impulsivity in suicide is likely to be
small, whereas the World Health Organization states that “many suicides
happen impulsively in moments of crisis with a breakdown in the ability to
deal with life stresses, such as financial problems, relationship break-up or
chronic pain and illness” (WHO, 2018).
Another Perspective
Other Working Group members hold that suicide prevention activities — ranging
from interventions with suicidal people, to national policies such as restricting
access to lethal means — can be justified by ethical beliefs and practical
experiences. However, in the view of these Working Group members, the main
justification for suicide prevention in Canada is the concern expressed in the
preamble to Bill C-14, in The Federal Framework for Suicide Prevention, in various
provincial and territorial mental health laws, and within suicide prevention
communities and organizations: society engages in suicide prevention because
of the belief that there is value in saving the lives of people who, although
feeling hopeless, have the potential to enjoy fulfilling lives when provided with
adequate treatment, help, and support.
Canada has suicide prevention measures, policies, and practices — including

laws on involuntary commitment — that do not refer to religious considerations
or authenticity. From a suicide prevention perspective, there is no distinction
made between suicides that are to be prevented and those that are not to be
prevented.
People involved in suicide prevention may adhere to a wide range of ethical

perspectives concerning suicide, of which the four justifications provided
in the previous section (One Perspective) are a limited sample. Mishara and
Weisstub (2010) explain that the ethical views and empirical presuppositions
of a person involved in suicide prevention will have implications for the nature
of interventions that they use when a suicide is imminent, but none of these
contravene work to prevent deaths by suicide in any group. In addition to the
four justifications provided in the previous section (One Perspective), Mishara
and Weisstub (2010) emphasize that consequentialist ethical arguments pervade
the suicide prevention community. People who work in suicide prevention are
encouraged to continue their work because people whose deaths by suicide were
prevented are generally thankful, do not attempt suicide again, and therefore
have the opportunity to go on to live fulfilling lives (Mishara & Weisstub,
2010). Some suicide centres report that people who are rescued — against
their wishes — from dying by suicide often call back to thank the centre for
saving their lives (Mishara & Weisstub, 2010).
As noted above, the ethical philosophies of suicide prevention workers may

determine their view on the acceptability of potentially intrusive interventions
(e.g., tracing a telephone call and sending an ambulance, or hospitalizing a
person who is considered to be at risk of suicide). However, these philosophies
are not relevant to the decision to provide help to suicidal people to prevent an
avoidable death. Two large suicide prevention organizations, the Samaritans (in
the United Kingdom) and Befrienders Worldwide, are non-political, non-sectoral,
and believe that the right of people to make their own decisions — including
whether to live or die — must always be respected (Bale, 2003). Despite this, the
Samaritans still attempt to convince callers not to end their lives, regardless of
the circumstances. If their efforts fail and the caller still proceeds with a suicide
attempt, the Samaritans will not trace calls in order to send an ambulance,
but will stay on the line and try to convince the person to accept medical help
(Samaritans, 2018). This differs from the approach of the American Association
of Suicidology (AAS), an organization that accredits suicide prevention centres
in the United States. The AAS requires more extraordinary actions be taken
to prevent death, including tracing a call to send emergency services (AAS,
2012). Mishara and Weisstub (2010) explain that the Samaritans are successful
in preventing suicide, stating “it is the experience of Samaritan organizations
that most people, once they begin to talk about their distress and despair,
become less suicidal, and that those who are still at high risk or have initiated
an attempt generally ask for help.”
The views of these other Working Group members on ambivalence, impulsivity,

incapacity, and authenticity, and how these are (or are not) relevant for suicide
prevention are as follows:
• Ambivalence: These Working Group members note the dominant perspective

in suicide prevention literature is that ambivalence in persons who are suicidal
involves the co-existing desire to live with the desire to die (Shneidman, 1972,
1996; WHO, 2000). These Working Group members believe that this tension
between the will to live and a desire to kill oneself is present in almost all
suicidal people. Interventions with suicidal people work by shifting the balance
between the will to live and die, and while suicidal thoughts may persist, they
can be outweighed by a stronger desire to continue living. In the view of these
Working Groups members, the legal test for capacity in Canadian law and the
usual methods of assessing it do not necessarily take into consideration this
ambivalence about wanting to die, although stability of choice is part of the
most widely used clinical model of capacity (Appelbaum & Grisso, 1988).
The view that ambivalence about whether to live or die is a characteristic

of suicidal individuals can be considered a complementary justification for
suicide prevention (WHO, 2000). Research shows that the vast majority of
people who seriously consider suicide will never attempt suicide, and only
approximately 5% of people who attempt suicide will die from their attempt
(WHO, 2014a). Most people who initiate a suicide attempt do not die (WHO,
2014a). The reason that so few die is not that humans are generally incapable
of ending their own lives. Rather, the majority of those who attempt suicide,
if they are physically able, stop the attempt or call for help and thus avoid a
lethal outcome (Mishara & Tousignant, 2004).
It has been shown that ambivalence about whether to live or die can fluctuate
with one’s experiences (Bergmans et al., 2017). Although having attempted
suicide is a significant risk factor for attempting again, with roughly 10%
of attempters making a second suicide attempt in the following year, the
majority do not attempt again (Chung et al., 2012; Murphy et al., 2012; Kwok
et al., 2014; Martiniuk et al., 2015; Owens et al., 2018). In addition, suicide
prevention centres report that almost all people who survive a suicide attempt
against their will thank the responders once they are out of danger (Mishara
& Tousignant, 2004).
Furthermore, in the view of these Working Group members, no suicides can be

considered entirely rational. The entry on Rational Suicide in the Encyclopedia
of Death and Dying argues that when people talk about rational suicide they
usually mean that the reasons given for the suicide can be understood by
someone else (Mishara, 2003). There are strong emotional components to
suicidal decision-making (as with all human decisions), regardless of peoples’
rational abilities to come up with justifications.
• Impulsivity: The extent to which impulsivity is involved in suicide is a matter

of debate, and its relevance to MAID (where there is a delay between request
and procedure) is uncertain. Research shows that, in impulsive suicide
attempts, the delay between the decision to kill oneself and the suicide attempt
is, on average, a matter of minutes or a few hours at most. For example, in
reported impulsive suicide attempts, less than five minutes elapse between
a person’s decision to attempt suicide and their suicide attempt (Simon et
al., 2001). Impulsive suicides typically occur in acute crisis situations (e.g.,
learning that a spouse is leaving, losing a job, or when being surrounded by

police after committing a crime), and usually when some means to attempt
suicide is easily accessible (WHO, 2014a).
The World Health Organization (WHO) affirms that, when suicide is

considered on a worldwide scale, many suicides occur in crisis moments
related to life stresses (e.g., financial problems, relationship break-ups)
(WHO, 2018). However, the WHO findings about suicide around the world
must be understood in the context of regional differences. Impulsivity in
suicide attempts is common in Asia (Anestis et al., 2014). For example, Wei
et al. (2013) found that 45% of suicide attempts were impulsive, with less
than two hours between the time someone first decides to attempt suicide
and their attempt, often when the person has consumed large quantities
of alcohol. But in Western countries such as Canada, impulsive suicides
constitute a small percentage of all suicide deaths, and they often occur when
the person has consumed alcohol or taken illicit drugs. The aforementioned
meta-analysis by Anestis et al. (2014) found that there is a very small, non-
significant relationship between impulsivity and suicide in Western countries.
Thus, these Working Group members believe, because people cannot use
MAID to complete an impulsive suicide (since MAID is not permitted within
hours of making a request), discussion of impulsive suicides is not relevant
to MAID MD-SUMC.
• Incapacity and Authenticity: In the view of some Working Group members,

the issues of incapacity and authenticity are not relevant to the practice of
suicide prevention. For example, suicide prevention hotlines do not assess
capacity or authenticity — they simply do their best to intervene to stop suicide.
In the experience of these Working Group members, people who engage
in suicide prevention do so regardless of issues of capacity and incapacity,
and authenticity is never considered in contemporary suicide prevention
practices. As illustrated by the practice of the Samaritans, people who are
viewed as fully capable of autonomous decision-making still receive intensive
suicide prevention interventions, regardless of their life circumstances and
the source of their suffering and despair.
Suicide Prevention and Bill C-14

Some Working Group members believe that with the passing of Bill C-14, society
no longer seeks to prevent all suicides. They believe that while alternatives to
suicide must first be offered to all patients, society now allows medical and
nurse practitioners to aid suicide where the conditions for self-administered
MAID are met. In the view of these Working Group members, while suicide
prevention professionals may disagree, society no longer sees all suicides as

a harm. That said, most suicides are clearly still seen as harms and most are
clearly still to be prevented. Thus, in their view, Bill C-14 requires society to
ask the question of how to distinguish between suicide that society seeks to
prevent and MAID when it meets the criteria of Bill C-14.
This contrasts with the view of other Working Group members, who believe
the legalization of assisted suicide under Bill C-14 was not intended to change
society’s commitment to preventing all suicides, nor was MAID (under the
current law) intended to be legalized as an alternative to suicide. These Working
Group members believe that, because of the “natural death has become
reasonably foreseeable” criterion (GC, 2016b), people eligible for MAID under
Bill C-14 are effectively advancing the timing of their death and changing the
manner in which they will die. Suicidal people are rarely in a situation where
their natural death is reasonably foreseeable. In a study of reasons for suicide
given by 4,673 people who attempted suicide in nine European countries, only
4.3% said that physical disorder was the main reason for their suicide attempt
(Burón et al., 2016). In a different study of suicide attempts among gay men
in Switzerland, only 2.6% (3 out of 127) said that their attempt was associated
with physical disorder (Wang et al., 2015). People who attempt suicide often
have one or more mental disorders (Section 3.2.1).
4.2.2 Can Suicide Be Reliably and Validly Differentiated from

MAID MD-SUMC?
Working Group members also diverged on the answer to the question of whether
suicide can be differentiated from MAID MD-SUMC. In this section, these two
divergent viewpoints are described.
One Perspective
Some Working Group members note that suicide can be defined as a situation in
which a person intentionally ends their life to terminate suffering they perceive
as being intolerable, interminable, and inevitable (Mishara & Tousignant,
2004). In contrast, MAID is defined as: “(a) the administering by a medical
practitioner or nurse practitioner of a substance to a person, at their request,
that causes their death; or (b) the prescribing or providing by a medical
practitioner or nurse practitioner of a substance to a person, at their request,
so that they may self-administer the substance and in doing so cause their own
death” (GC, 2016b).
Some Working Group members believe that a recent statement from the
American Association of Suicidology (AAS, 2017), which claims that physician
aid in dying (PAD) can be distinguished from suicide that should be prevented,
is not evidence-based. The AAS statement maintains that suicide is not the
same as PAD as it is currently practiced in jurisdictions that permit it, and notes
15 differences between PAD and “suicide in the ordinary, traditional sense”
(AAS, 2017). However, while the AAS statement is intended to cover all existing
assisted dying practices, including assisted dying for people with a mental
disorder as their sole underlying medical condition, most of the differences
between suicide and PAD identified by the AAS are differences between suicide
and PAD for a terminal illness, or between suicide and cases where a person’s
natural death is otherwise reasonably foreseeable (Kim et al., 2018). As such,
in the view of these Working Group members, the AAS statement does not
explain how to distinguish between traditional suicides (which they seek to
prevent) and MAID MD-SUMC (AAS, 2017; Kim et al., 2018).
Despite advances in the understanding of the risk factors for suicide (Section 3.2),
there remains an important limitation when it comes to predictability. While the
risk factors for suicide are well known, they cannot be applied in a straightforward
manner to people in order to reliably predict who will and will not die by suicide.
This means that, despite the fact that suicide, assisted suicide, and euthanasia have
different definitions, some Working Group members believe it is not possible
to distinguish empirically between people who are suicidal from those who
have made an autonomous request for MAID MD-SUMC. There is evidence
that some patients who have sought psychiatric EAS in jurisdictions that permit
it share key features with those who make suicide attempts (these features are
discussed in Chapter 3; international data are discussed in Chapter 5). These
shared features include: having psychiatric disorders that are risk factors for
suicide; ambivalence (as demonstrated by people withdrawing their psychiatric
EAS requests either before or after approval16 (Thienpont et al., 2015)); a
demoralized belief that life is unbearable and that no solutions are possible;
and being socially isolated or lonely (Kim et al., 2016). These are all features
of suicide that ought to be prevented, as defined by AAS (AAS, 2017).
WHO considers suicides preventable (WHO, 2014a) and its public health
perspective informed the development of Canada’s An Act Respecting a Federal
Framework for Suicide Prevention (GC, 2016c). Many countries engage in a range
of suicide prevention activities, from interventions with suicidal people to
16 Out of a total of 100 applications for psychiatric EAS in Belgium, 11 postponed or cancelled the
procedure after approval (for 8 patients “simply having this option gave them enough peace
of mind to continue living,” 2 withdrew requests due to strong family resistance, and 1 person
could not have EAS because they were incarcerated), while 38 withdrew their requests before
a decision was reached (Thienpont et al., 2015).
national policies such as restricting access to lethal means. Some Working Group
members believe expanding MAID MD-SUMC could significantly affect suicide
prevention strategies in Canada, as healthcare practitioners would no longer
strive to prevent the suicide of everyone with a mental disorder who wants to
end their life (See Chapter 6 for a discussion of the implications of prohibiting
or more broadly permitting MAID MD-SUMC on suicide prevention).
Unlike many physical disorders, the effectiveness of treating some mental

disorders is generally determined by a trial and error approach; if certain
treatments do not adequately alleviate symptoms, alternative treatments are
tried (Section 3.1.2). As noted in Section 4.1.2, Canadian MAID law does not
require a patient to try potential treatments that a healthcare practitioner may
believe could alleviate the suffering that motivates the patient’s request for
MAID (GC, 2016b). Rather, a patient can refuse any potential treatment that
they do not consider to be acceptable. As such, Canadian MAID legislation
differs from EAS law in the Netherlands, which requires that both the healthcare
practitioner and the patient agree together that there are no available, untried
treatments that might alleviate the patient’s suffering before they can access
EAS (Chapter 5). These Working Group members believe that, because of
the ethical distinction between hastening a foreseeable death and providing
MAID to someone who is not terminally ill, and because interventions for
mental disorders require trial and error to determine their effectiveness in
treating the symptoms that cause suffering, a potential safeguard to consider is
requiring physician agreement on the futility of untried treatment options as a
prerequisite to granting a request for MAID MD-SUMC, should it be expanded
(Section 6.4.8). These Working Group members believe that this is an ethical
imperative supported by existing mental health legislation throughout Canada
that recognize people with mental disorders as a vulnerable population that
needs specific protections.
In the view of these Working Group members, if MAID MD-SUMC were more
broadly permitted in Canada under the current situation wherein the capable
patient alone determines whether any potential treatment is acceptable, it could
have important implications for suicide prevention and further problematize
how some people with mental disorders (and society) view their prognosis
(Chapter 6). Many suicide prevention efforts focus on building hope regardless
of the person’s state of despair (WHO, 2014a). At the present time, it is difficult
to accurately determine whose symptoms can be alleviated and whose cannot,
unless a range of treatments are tried (Section 3.1.2). In addition, these Working
Group members believe that there is also no method to conclusively determine
whether an individual’s desire to die is pathological and should be treated
aggressively, or whether a MAID MD-SUMC request should be facilitated. They
believe that if treatment futility is left up to the patient alone to determine, as
is the case in current Canadian MAID legislation, suicidal people who currently
benefit from treatment for their symptoms and feelings of hopelessness may
have their deaths facilitated if they request MAID MD-SUMC.
These Working Group members do not believe that Bill C-14 has shifted the way
suicide prevention is viewed in Canada. For example, mental health legislation
in most provinces and territories allows for involuntary hospitalization in specific
circumstances when a person lacks capacity and is in danger of attempting
suicide due to a mental disorder (Section 3.6.3). Furthermore, people who
work in suicide prevention are not neutral, as they intervene in any potential
suicide (including non-mental disorder suicides) and with people who would
otherwise meet the eligibility criteria for MAID. In the view of these Working
Group members, the only circumstance where suicide prevention interventions
are not offered is when MAID is provided to someone who meets all requirements
under C-14 (including that their death is reasonably foreseeable). Further,
these Working Group members believe that people who qualify for MAID
under Bill C-14 rarely come into contact with suicide prevention workers but,
if they did, their desire for death by MAID and potential ambivalence would
be explored and help would be offered (without interfering with their MAID
request).
Another Perspective
Other Working Group members note that some suicide prevention organizations
have argued that suicide can be differentiated from MAID. For example,
the Centre for Suicide Prevention, a branch of the Canadian Mental Health
Association, has developed a graphic to explain the differences between suicide
and MAID (in reference to people accessing MAID who would be eligible under
the current law) (Centre for Suicide Prevention, 2016).17
Nevertheless, these other Working Group members believe that the concepts
of suicide and MAID are themselves overlapping, for the following reasons:
• Suicide and MAID fall within a broad category of self-directed death.
• Unassisted suicide and self-administered MAID are forms of suicide.
• Legally speaking, self-administered MAID is a sub-category of assisted suicide
(i.e., it is medically-assisted suicide).
These Working Group members believe that, through Bill C-14, society has
determined that some self-directed deaths are to be facilitated, some are to be
prevented, and some are to be neither facilitated nor prevented. The current
17 As noted above, the American Association of Suicidology has also taken the position that suicide
can be differentiated from physician aid in dying (AAS, 2017).
eligibility criteria offer a normative threshold for determining who should

receive MAID by providing ethical and legal standards in deciding whose deaths
should be facilitated. Whether these criteria offer an adequate normative
threshold for MAID MD-SUMC, and if so, with what accompanying safeguards,
are ethical questions. If MAID MD-SUMC were expanded, the challenge would
be to determine criteria for access that both facilitate suicide prevention (and,
in some cases, restrict liberty or prohibit a third party’s conduct to do so) for
those suicides that society has determined should be prevented, while providing
MAID to those whom society has determined should be eligible.
Some Working Group members believe that society has already made certain
judgments about how to respond to various requests for or attempts at self-
directed death. For example, society may:
• limit a person’s liberty to prevent harm to themselves or others due to a
mental disorder (through the procedures allowed by mental health legislation
in some jurisdictions);
• prohibit aiding, abetting, and counselling in regards to suicide (that does
not meet the eligibility criteria for MAID);
• not interfere in or facilitate a person’s suicide in cases where they are not
a danger to self due to a mental disorder and do not meet the eligibility
criteria for MAID;
• allow access to MAID where a person meets all the eligibility criteria in the
federal legislation.
In the view of these Working Group members, society may shift its judgments
related to self-directed death in the future. For example, society may decide
to limit involuntary hospitalization of those who pose a danger to themselves
due to a mental disorder to only those who lack decision-making capacity,
or it may decide to require a finding of non-ambivalence for all refusals of
life-sustaining treatment, or it may decide to change or remove one or more
criteria for MAID eligibility.
4.2.3 Impact of Legalized MAID on Suicide Rates

There are some data on the impact of legalizing assisted dying on suicide rates,
but none of this research focuses specifically on assisted dying for people with a
mental disorder as their sole underlying medical condition. A 2015 regression
analysis found “no evidence that PAS [physician-assisted suicide] is associated
with reductions in the non-assisted suicide rate or with increases in the mean
age of death for non-assisted suicide” (Jones & Paton, 2015). Furthermore,
commenting on Jones and Paton (2015), Lowe and Downie (2017) note the
evidence also shows “that non-assisted suicide rates were already changing in
states with PAS before it was legalized, and that legalization had no effect”
on suicide rates in these jurisdictions. However, Jones and Paton (2015) only
examined suicide rates in U.S. states that have legalized assisted dying, and
none of these jurisdictions permit assisted dying for mental disorders.
In jurisdictions where psychiatric EAS is permitted, OECD data show that,

on average, the non-assisted suicide rate decreased in the Benelux countries
between 1990 and 2016 (OECD, 2018). More recently, the suicide rate has
increased in the Netherlands since 2007, while remaining relatively stable in
Belgium. Generally, suicide rates are decreasing worldwide (WHO, 2014a).
There is no evidence of any association between the legal status of assisted
dying in a country and its suicide rate: some jurisdictions where assisted dying
is legal have higher suicide rates than jurisdictions where the practice is illegal,
and vice-versa (OECD, 2018). Suicide rates in any given country are related
to a multitude of factors.
4 . 3 VULN E R A B I L I T Y AND AU T ONOM Y
As the Bill C-14 preamble states, protecting vulnerable people from ending their
lives in a moment of weakness is an objective of the legislation (GC, 2016b).
Another objective is to “[recognize] the autonomy of persons who have a grievous
and irremediable medical condition that causes them enduring and intolerable
suffering” (GC, 2016b). There is often a tension between respecting autonomy
and protecting the vulnerable: permitting MAID MD-SUMC more broadly may
recognize and respect the autonomy of people with mental disorders, but it
may also increase the risk of harm to this potentially vulnerable population
(see Chapter 6 for further discussion). Indeed, Canada has a history of denying
autonomy to people with mental disorders and failing to respect their choices
for their own protection. In the view of the Working Group, respecting the
autonomy of people with mental disorders may be viewed through the lens of
protecting vulnerable people overall.
4.3.1 Vulnerability
People with mental disorders are sometimes considered to be vulnerable,
insofar as some have an increased risk of experiencing inequalities such as
socio-economic hardship (e.g., poverty, housing instability), lack of social
support, discrimination and stigma, violence and abuse, and disability (i.e., a
reduced ability to defend or promote their own interests). Furthermore, the
vulnerability of people with mental disorders is legally recognized in Canada,
both in provincial and territorial Human Rights Codes and in the Canadian
Charter of Rights and Freedoms, which explicitly prohibits discrimination on the
basis of mental disability. Historically, broad practices introduced to protect
vulnerable groups have been used to justify the exclusion of people with
decision-making capacity from participating in activities, such as biomedical

research, which those same people may consider to be of personal or group
benefit (Rhodes, 2005).
In Canada, the Vulnerable Persons Standard (VPS) was developed “by a body of
advisors with expertise in medicine, ethics, law, public policy and needs of
vulnerable persons” in response to the Carter decision, to “ensure that Canadians
requesting assistance from physicians to end their life can do so without
jeopardizing the lives of vulnerable persons who may be subject to coercion
or abuse” (VPS, 2017). The VPS notes that extraneous factors, unrelated to
their medical condition, may influence a vulnerable person’s decision-making.
Rooney et al. (2017) propose that the key vulnerability factor for psychiatric
patients that is specifically relevant to MAID is the difficulty in determining
whether such patients have the decision-making capacity to make the request.
These authors argue that other factors that influence vulnerability, such as
abuse, fraud, poverty, and violence, are equally applicable to patients with
terminal illnesses as they are to psychiatric patients. While all people are initially
presumed to have decision-making capacity in Canada, healthcare practitioners
are required to conduct capacity assessments before a patient can qualify for
MAID if they suspect that a person’s capacity might be impaired.
4.3.2 Autonomy
The concept of autonomy is fundamental to MAID MD-SUMC. Autonomy
provides the basis for informed consent, and arguments for both permitting and
prohibiting MAID MD-SUMC are based on the value of respecting the autonomy
of people with mental disorders. However, the concept of autonomy is complex
and can be defined in different ways. Traditionally, people are thought to be
autonomous when they have the capacity for self-determination and the ability
to make decisions according to their own values and beliefs, free from coercion
and outside interference (Christman, 2018). A person who lacks autonomy
is in some sense “controlled by others or incapable of deliberating or acting
on the basis of his or her desires or plans” (Beauchamp & Childress, 2013).
In the individualistic view of autonomy, individuals are seen as independent

decision-makers, and respecting their autonomy requires both non-interference
in their decision-making and ensuring they have the necessary information to
make an informed decision. Once relevant and desired information is available,
individuals have the right to make a decision that accords with their own personal
values, preferences, beliefs, and desires, without controlling interference
or limitations that prevent meaningful individual choices (Beauchamp &
Childress, 2013).
The individualist notion of autonomy has been challenged by critics who

advocate a relational view of autonomy (Mackenzie & Stoljar, 1999; Sherwin,
2012). This view emphasizes that individuals are embedded in a network of
social, political, and economic relationships with others, and that autonomy
depends on such relationships (Hall, 2012). In this view, it is not the mere ability
to make a decision that is important; rather “[a]utonomy becomes possible in
social interactions through relationships” (Leckey, 2008).
[R]elational autonomy embraces (rather than ignores) the fact that

persons are inherently socially, politically, and economically-situated
beings. A relational approach to autonomy directs us to attend to
the many and varied ways in which competing policy options affect the
opportunities available to members of different social groups [...] and
to make visible the ways in which the autonomy of some may come
at the expense of others. Relational autonomy encourages us to see
that there are many ways in which autonomy can be compromised. It
allows us to see that sometimes autonomy is best promoted through
social change rather than simply protecting individuals’ freedom to act
within existing structures.
(Kenny et al., 2010)
In some relational views, appropriate inclusion of family and healthcare

practitioners during medical decisions is a way to foster — and not detract
from — autonomy. Indeed, it has been argued that MAID, as an act that
inevitably involves both patient and healthcare practitioners, and will implicate
family and others, is an inherently relational act and, as such, should be
conceptualized within the framework of relational, rather than individual,
autonomy (Deschamps, 2016).
Further, relational views of autonomy emphasize not just the importance of

interpersonal relationships in the provision of healthcare, but also the socio-
political contexts in which healthcare is delivered. As noted in Chapter 3, there
are long-standing inequities in access to resources for health and appropriate
healthcare, particularly in the realm of mental healthcare. Conceptualizing
autonomy as relational underscores the need to “better understand and deal
with the complex socio-political climates in which health care is delivered and in
which resources for health are embedded” (Rodney et al., 2013). Furthermore,
relational views of autonomy provide a framework for understanding how
various social determinants of mental health (e.g., unstable housing, financial
hardship, stigma and discrimination, as noted in Chapter 3) can affect the
autonomy of people with mental disorders.
Some Working Group members expressed concerns about the impact of

constrained choices on autonomous decision-making. They consider that,
whereas the individualistic conception of autonomy emphasizes lack of outside
interference, other conceptions of autonomy emphasize that no one can be
truly autonomous if they are not supported socially, culturally, and economically
(e.g., McLeod & Sherwin, 2000; Beaudry, 2018). These Working Group members
state that this broader conception of autonomy demonstrates how a strictly
subjective definition of irremediability of suffering (such as the one found in
Bill C-14) could be discriminatory and disrespectful of someone’s autonomy.
Specifically, they believe that if an individual receives MAID because they
cannot obtain resources (e.g., mental healthcare, social support) that society
can provide, then that person is not being respected as autonomous. Rather,
they are forced into a choice they do not truly wish to make, and as such the
choice is not autonomous. For example, the plaintiff in the ongoing Foley case
in Ontario (ONSC, 2018) claims he was offered MAID but was not provided
with the option of self-directed management of homecare (Section 6.1.3).
Moreover, these Working Group members believe that if the lack of resources
is based on historical abuses or inequalities linked (for example) to gender,
ethnicity, or disability, the lack of freedom of choice is especially discriminatory
and damaging to the person’s autonomy.
Other Working Group members believe that all decisions are made under
conditions of constrained choice, and under variable social, cultural, and
economic conditions. They expressed concern that characterizing the decisions
of socially, culturally, or economically marginalized people as non-autonomous
puts those people at risk of having their decisions disregarded or not invited in
the first place. Further, these Working Group members believe that if the type
of social, cultural, and/or economic supports required to satisfy others that a
person’s decisions meet some threshold of autonomy are unlikely to be provided,
then characterizing that person’s decisions as non-autonomous amounts to
paternalism, compounding their marginalization and lack of freedom. In the
view of these Working Group members, such treatment would be discriminatory
and disrespectful of capable people’s right to self-determination as they make do
as best they can in an imperfect world. Further, these Working Group members
believe that even if such choices are being withheld from people with a mental
disorder in order to bring about positive social change (e.g., reducing social
inequality, or increasing resources for mental healthcare), these people are
nevertheless potentially being used to serve others’ objectives. In the view of
these Working Group members, a preferable approach would be one that seeks
to maintain maximal freedom for the self-determination of capable people
within constrained circumstances, while also seeking to remedy unjustified
inequalities (Downie & Sherwin, 1996).
Autonomy and Mental Disorders

Whereas autonomy is often characterized by an absence of external interference,
mental disorders can be understood as a kind of internal interference
(Widdershoven & Abma, 2012). That is, pathological states of mind (e.g.,
depression, anxiety, delusion) can interfere with or distort a person’s normal
pattern of thoughts, feelings, and behaviour, potentially impairing their decision-
making capacity or leaving them unable to reason rationally, perceive their
situation clearly, or pursue their desires, preferences, and goals in accordance
with their values. As Bolton and Banner (2012) put it, “a person’s mental states
and behavior, when mentally ill, may not be considered a true expression of
themselves, but rather as expressions of the illness, and therefore as lacking
autonomy in this sense.” In short, a person whose decisions are controlled by
their mental disorder is not autonomous.
For these reasons, it is difficult to know when a person’s mental disorder may
be interfering with their decision-making, or whether the decisions that they
make reflect their beliefs, desires, values, and preferences. In some instances,
protecting a person’s autonomy might even require involuntary hospitalization
and/or forced treatment to determine if they pose a danger to themselves
or others. Such measures are predicated on the belief that the person is not
currently behaving autonomously due to an ongoing episode of their mental
disorder, which will abate with time and/or treatment. This amounts to protecting
the autonomy of a person’s future self from the non-autonomous decisions of
their current self.
Similarly, in situations where involuntary hospitalization is not warranted

(because the person does not pose a threat to themselves or others), respecting
the autonomy of people with mental disorders might require more than
simply doing whatever the patient desires. In a relational view of autonomy,
the goal of good clinical practice is to help the patient develop their capability
for autonomous decision-making. This is accomplished by engaging with the
patient in a reciprocal dialogue, exploring the desires, values, and preferences
of the patient, as well as helping them to examine, evaluate, and deliberate
about those values and preferences in order to make an autonomous decision
(Kim, 2010; Widdershoven & Abma, 2012).
4.3.3 Impact of Mental Disorders on Decision-Making

Fully assessing the impact of a mental disorder on a person’s decision-making
may demand a more thorough evaluation than that required to meet the
legal standard for capacity. While the autonomous choices of a person whose
decision-making capacity is intact must be respected, some have suggested
that “respecting and promoting patient self-determination requires more than

simply doing whatever the patient wants, and to ensure that what the patient
wants is what he truly desires” (Kim, 2010).
This suggestion is driven by the perceived professional responsibility of clinicians

to consider the ways in which a mental disorder might be affecting a patient’s
decision-making, even when that person has legal capacity. A clinician might
consider a patient’s past decisions leading up to the request for MAID, such as
the decision of whether or not to engage in treatment; the decision to isolate
themselves socially; ambivalence, indecision and regret after suicide attempts;
and so on. This is because mental disorders can significantly affect a person’s
decision-making, even in cases where they have capacity. However, a capable
person’s wishes cannot legally be overruled, even if a clinician believes they are
not autonomous because a mental disorder has influenced their decision-making.
In addition to requiring that the patient have capacity, the law in the Benelux
countries requires that a patient’s decision for EAS must be voluntary and
well-considered (Gov. of Belgium, 2002; Gov. of the Netherlands, 2002; Gov. of
Luxembourg, 2009). The Dutch RTE Code of Practice explains that the “well-
considered” criterion requires that “the patient has given that matter careful
consideration on the basis of adequate information and a clear understanding of
his illness,” that the patient has not made the request on impulse, and that the
patient’s request is consistent, “taking account of all the patient’s circumstances
and utterances” (RTE, 2015b). In the case of patients with mental disorders, the
RTE Code of Practice goes further, stating that the “well-considered” criterion
also requires that “it must be ruled out that the patient’s psychiatric disorder
has impaired his ability to form judgments” (RTE, 2015b).
In the Canadian context, there is no distinction made between having the

capacity for a decision and the degree to which a decision is well-considered.
It is possible that a patient with a mental disorder might be found to have the
legal capacity to consent to MAID, and yet their decision would not be well-
considered by the standards of the Benelux countries, due to the influence
of that person’s mental disorder on their decision-making. How these criteria
are implemented in the Benelux countries is discussed in Chapter 5, and
their potential implications for the practice of MAID MD-SUMC in Canada is
discussed in Chapter 6.
4 . 4 M E N TA L HE ALT H CAR E AND T RE AT M ENT
For many people with mental disorders, effective treatment can profoundly
improve their quality of life (Ratnasingham et al., 2012). However, there is also
evidence that some conditions are difficult to treat. For example, a review of the
literature of treatment-resistant depression found that despite trying multiple
medications and other “more aggressive” treatment regimes, 15% of patients
diagnosed with major depressive disorder continue to experience symptoms of
depression, and about 20% of patients with depression experienced symptoms
up to two years following a major depressive episode (Trevino, 2014).
Nevertheless, it is rare that a patient does not make any improvement with
treatment. Symptom combinations tend to be complex, and some symptoms
may improve while others may not. However, in the Working Group members’
clinical expertise, the most likely outcome is improvement in general. The
question remains, however, whether this improvement relieves the patient’s
suffering to the point where they no longer experience it as intolerable. For
example, a patient may have improvement in their mood without improvement
in their sleep, and still suffer due to their mental disorder.
A single mental disorder may have a number of symptoms and impacts. For
instance, depression may affect sleep, energy, appetite, mood, one’s ability to
think clearly, and one’s perception of the past and future (APA, 2013). This
may have impacts on a person’s job performance, relationships, and ability to
carry out parenting roles. Treatment of depression may include increasing the
patient’s knowledge about the disorder (and the knowledge of their friends
and family), evaluating and reducing the stressors in their life, psychotherapy,
exercise, diet, medication, and/or couple or family therapy (APA, 2010). In
some cases, deep brain stimulation or ECT may be recommended. Different
treatments can have different impacts on the complex set of psychological,
social, and biological factors that are linked to the persistence of depression.
Treatment impact varies from person to person.
When left untreated, the course of a mental disorder varies for different mental
disorders and for different people. Some mental disorders are characterized by
a single episode followed by a complete remission of symptoms (APA, 2013),
but courses vary even in disorders that can be chronic and persistent. For
example, about 25% of people with schizophrenia experience a single episode
that fully subsides, while the majority will have a lifelong condition with episodic
relapses and remissions (Rosen & Garety, 2005). Variable outcomes are also
found in severe depression and bipolar disorder (APA, 2013). In addition, some
conditions that have historically been considered to be lifelong problems, such

as personality disorders, are now understood to improve over time in some
people, or show significant fluctuations (Gunderson et al., 2011).
4.4.1 Recovery-Oriented Practice

In 2012, the Mental Health Commission of Canada developed the Mental Health
Strategy for Canada, which takes a recovery-oriented approach to the treatment
of mental disorders. In this context, the term recovery refers to one’s ability to
live “a satisfying, hopeful, and contributing life, even when there are ongoing
limitations caused by mental health problems and illnesses” (MHCC, 2012).
The goal of recovery-oriented practice is to improve the quality of life for
people with mental disorders and allow them to “engage in a life of meaning
and purpose” (MHCC, 2012). The concept of recovery is not synonymous with
cure, nor does it necessarily imply remission of symptoms or return to normal
functioning (Jacobson & Greenley, 2001; Davidson & O’Connell, 2005; Davidson
& Roe, 2007; MHCC, 2012).
One of the most influential recovery models is Europe’s CHIME model (Leamy
et al., 2011). Built on a systematic review and narrative synthesis of personal
recovery, CHIME stands for: Connectedness; Hope and optimism about the
future; Identity; Meaning in life; and Empowerment. A 2011 systematic review
and narrative synthesis of information obtained from minority ethnic groups in
Europe identified similar themes of recovery, but placed additional emphasis
on two particular aspects of recovery: spirituality and stigma. Moreover, this
analysis identified two additional themes in recovery for minority ethnic groups,
namely, “culture-specific factors and collectivist notions of recovery” (Leamy
et al., 2011).
Rather than focusing on symptom reduction or improved functioning with

respect to treatment outcomes, clinicians in Canada increasingly include
concepts of recovery such as CHIME when developing indicators. Advocates of
recovery-oriented practice argue that recovery principles offer a valuable basis
for how mental healthcare services should be developed and delivered. The
recovery model is now “recognized as key to achieving better mental health
outcomes and improving mental health systems” (MHCC, 2015, 2018), and
most provinces and territories have begun to incorporate the model into their
mental health policies, strategies, and planning documents (MHCC, 2015).
4.4.2 End-of-Life Treatment Preferences in People

with Mental Disorders
Potentially useful insights about MAID MD-SUMC may be gained by considering
end-of-life decision-making and treatment preferences in people with mental
disorders. Research on this topic typically focuses on end-of-life decision-making
in people with mental disorders who also have a co-morbid life-limiting physical
illness. Thus, although this evidence does not examine people for whom a
mental disorder is their sole underlying medical condition, it may nevertheless
offer insight into a field that has considered the impacts of mental disorders
on end-of-life preferences and clinical practice.
The American Psychiatric Association has developed a set of core principles

for end-of-life care in psychiatry (APA, 2001). These principles have been
described as recognizing “the rights of autonomy for people with palliative care
needs who also suffer with mental health issues” (Webber, 2012). Nevertheless,
researchers report that people with mental disorders may be marginalized from
end-of-life decision-making for a number of reasons, including a presumption
of incapacity, a concern that discussion of end-of-life issues could potentially be
emotionally and/or cognitively destabilizing, a lack of knowledge or training
about end-of-life care on the part of mental healthcare practitioners, and a
lack of training or knowledge about mental disorders on the part of end-of-life
healthcare practitioners (Foti, 2003; Foti et al., 2005a; Woods et al., 2008; Webber,
2012; Sweers et al., 2013; Shavlev et al., 2016). However, research demonstrates
that people with mental disorders are emotionally and cognitively capable of
discussing issues related to end-of-life decision-making without experiencing
ongoing negative effects (Foti et al., 2005b; Woods et al., 2008; Sweers et al.,
2013; Elie et al., 2017).
Two studies have compared the end-of-life treatment preferences in people

with mental disorders to other populations. A 2005 study reported that people
with a mental disorder were less likely to state they would discontinue certain
intensive end-of-life treatments (e.g., artificial life support) as compared to the
general population in other studies, although the results were similar to those
expressed by certain racialized groups who experience healthcare disparities
(Foti et al., 2005a). Sweers et al. (2013) reported that end-of-life perspectives
and expectations in people with schizophrenia were similar to those of the
general population.
Three studies have found commonalities in end-of-life concerns between

terminally ill people with and without a mental disorder, including the feeling
that one is a financial or emotional burden on loved ones; desire to control
symptoms, pain and suffering; control over degree of treatment in order to

avoid prolonging the dying process; and maintaining meaningful relationships
with those close to them (Foti et al., 2005b; Woods et al., 2008; Webber, 2012).
MAID as an End-of-Life Preference in People with Mental Disorders

There is conflicting evidence about whether people with mental disorders are
more or less likely to consider MAID in end-of-life situations. A 2005 study found
that only 34% of patients with a mental disorder would want a physician to
agree to a request to provide them with “enough medication to die by overdose”
in a hypothetical scenario involving terminal cancer with terrible pain (Foti
et al., 2005a); however, some may not consider this to be equivalent to MAID
MD-SUMC given that the mental disorder was not the sole underlying medical
condition motivating the request. Similarly, Elie et al. (2017) found that when
presented with a hypothetical scenario involving intractable pain or suffering,
people with severe and persistent mental illness (SPMI) were 52% less likely to
consider MAID than people with a chronic physical disorder. A majority (55%)
of SPMI patients in the study rejected MAID as an end-of-life treatment option,
and having an SPMI was found to be independently associated with decreased
support for MAID (Elie et al., 2017).
A 2001 study of depressed and non-depressed hospitalized older adults found

that, compared to non-depressed peers, depressed patients were 13 times more
likely to accept physician-assisted dying when considering their current situation
(and twice as likely in hypothetical scenarios of terminal illness or coma) (Blank
et al., 2001). A 2011 systematic review that examined the association between
depressive symptoms and requests for assisted dying found conflicting evidence
among the studies examined, although it concluded that the strongest data “do
not convincingly show that depression is more common in patients making a
request for euthanasia/PAS than in the surrounding population of terminally
or seriously ill patients” (Levene & Parker, 2011). However, nearly all of the
studies reviewed concerned depressive symptoms in patients who requested
EAS for a non-psychiatric terminal illness, not patients who requested EAS
for a mental disorder that was their sole underlying medical condition. A
more recent study by Elie et al. (2017) found no association between specific
psychiatric symptoms and a preference for MAID.
The implications of these studies for people who might request MAID MD-
SUMC and who are not currently eligible under the current law are not clear.
These studies typically examine the preference for assisted dying in situations
where a person with a mental disorder is suffering due to a physical condition
or terminal illness that would likely qualify them as eligible under the current
law, rather than situations where a person is requesting MAID MD-SUMC and
would not be currently eligible.
4.4.3 Stability of Treatment Preferences in People

with a Mental Disorder
The impact of a mental disorder on a person’s decision-making can vary over
time. This section examines the stability of treatment preferences in people
with a mental disorder. The stability of a treatment preference, however, may
not be a reliable indicator of the stability of a preference for MAID or a desire to
die. Moreover, people with mental disorders may change their treatment wishes.
Patients who are treated for their mental disorder against their will usually agree
that treatment was the best option once their symptoms improve (Owen et al.,
2009b; Tan et al., 2010). There is relatively little research on the impact that
mental disorders have on the stability of preferences for life-sustaining treatment.
Most existing studies have examined the impact of psychiatric symptoms such
as depression or anxiety on the stability of treatment preferences in people
with a serious physical condition or in older patients, with varying results.
A systematic review by Auriemma et al. (2014) identified eight studies that

examined the relationship between depression and stability of treatment
preferences. Four of the studies found no association. Two studies found that an
improvement in depressive symptoms was associated with an increased preference
for life-sustaining treatment in at least some senior psychiatric patients with
depression (Ganzini et al., 1994; Eggar et al., 2002). The two remaining studies
both examined the impact of worsening depressive symptoms on treatment
preferences, and had opposite findings. The first found that worsening symptoms
of depression were associated with a decreased preference for life-sustaining
treatment in patients with advanced, life-limiting physical disorders (Janssen
et al., 2012). The second found that worsening symptoms of depression were
associated with an increased preference for life-sustaining treatment in senior
primary care outpatients (Danis et al., 1994).
Studies have examined the stability of a person’s decision for psychiatric EAS in
jurisdictions that permit it (Groenewoud et al., 1997; Thienpont et al., 2015). As
discussed in more detail in Chapter 5, a 2015 analysis of 100 consecutive patients
in Belgium who made a request for psychiatric EAS found that 49 withdrew their
request before the procedure could be carried out (Thienpont et al., 2015). Of
those 49 people, 11 withdrew their request after it had been approved, whereas
the other 38 withdrew their request while it was still pending — i.e., before it
had been either approved or denied. Among these 38 patients, the reasons
for withdrawing their request are not known. However, among the 11 patients
who withdrew their request after it had been approved, 8 explained that knowing
they had the option of assisted death “gave them sufficient peace of mind to
continue their lives,” 2 withdrew their request due to strong family resistance,
and 1 was forced to withdraw because they were imprisoned (Thienpont et al.,
2015). See Chapters 5 and 6 for further discussion.
There is a need for better evidence on the validity of capacity assessment for
people with mental disorders, particularly but not exclusively for people who
request MAID MD-SUMC.
There is a lack of adequate evidence about the relationship among the severity
of symptoms of a person’s mental disorder, their quality of life, and their desire
for MAID.
It is unknown whether physicians who assess requests for psychiatric EAS in

jurisdictions that permit it have difficulty distinguishing between autonomous,
well-considered requests and pathological suicidal requests that are symptomatic
of a mental disorder.
There is inadequate evidence on any links among voluntariness, external

pressure, and MAID MD-SUMC requests. There is also a need for better evidence
on any links among voluntariness, paternalism, and denials of eligibility with
respect to MAID MD-SUMC.
Chapter 5 Assisted Dying for People with Mental Disorders Worldwide 109
5
Assisted Dying for People with
Mental Disorders Worldwide
• Why Look to International Evidence on

MAID MD-SUMC?
• The International Legal Landscape
• Sources and Quality of Evidence Relating

to Psychiatric EAS
• Psychiatric EAS: Frequency and Trends in

the Netherlands and Belgium
• Characteristics of Individuals Who

Request/Receive Psychiatric EAS
• Evaluation of Patients Requesting

Psychiatric EAS
• How Psychiatric EAS is Monitored in

• Implications of the International Data

5 Assisted Dying for People with Mental Disorders

Worldwide
Key Findings
About two decades of Dutch and Belgian experience offers evidence on MAID
MD-SUMC. Interpreting these data for Canada should take into account differences in
cultures, geographies, demographics, healthcare, and legal and regulatory structures,
but also commonalities in relative wealth, medical/scientific concepts and literature,
democratic ideals, and views on human rights (Section 5.1).
In the Netherlands and Belgium, psychiatric euthanasia and assisted suicide (psychiatric
EAS), excluding dementia, represent approximately 1 to 2% of all EAS cases (40 of
2,309 Belgian EAS cases and 83 of 6,585 Dutch EAS cases in 2017). The number
of psychiatric EAS cases have been increasing in recent years in the Netherlands
(Section 5.4).
There is a wide diversity of psychiatric conditions found among those who request
psychiatric EAS in the Netherlands and Belgium, but the highest number of requests
come from individuals with depression. Other conditions underlying requests include
personality disorders, schizophrenia and other psychotic disorders, post-traumatic
stress disorder and anxiety disorders, eating disorders, autism, and prolonged grief
disorder (Section 5.5).
In the Netherlands and Belgium, more than twice as many women than men seek and
receive psychiatric EAS, in contrast to all EAS cases, where the proportion of men and
women is roughly equal (Section 5.5). The reasons for the difference are unclear but
may be due to women having a higher prevalence of those psychiatric conditions
that more frequently lead to psychiatric EAS requests, which in turn may be due to
their greater exposure to social and economic inequalities.
Psychiatric EAS remains controversial even in jurisdictions that have permitted it for
many years, and public debate is ongoing (Section 5.2).
Social isolation and loneliness occur in about half of the people who request psychiatric
EAS in the Netherlands (Section 5.5).
The research on psychiatric EAS in the Netherlands and Belgium shows: that physicians
disagreed about patients’ eligibility for psychiatric EAS in 24% of Dutch cases; and,
38% of Belgians requesting psychiatric EAS withdrew their requests before a decision
continued on next page
was reached, 11% postponed or cancelled the procedure after their request was
accepted, and 57% of those who initially requested psychiatric EAS were alive one
to four years later (Section 5.6).
There has been an increase in the number of psychiatric EAS cases performed by a clinic
that specializes in providing EAS to individuals whose physicians have declined their
request in the Netherlands. Cases from this clinic are overrepresented among those
deemed by review committees as not having met legal due care criteria (Section 5.4).
Note on terminology: most references and reporting statistics from the Benelux
countries (Belgium, the Netherlands, and Luxembourg) use their legal terms
euthanasia and physician-assisted suicide; therefore, the acronym EAS is used in
this chapter, as is the term psychiatric EAS to refer to MAID where psychiatric
illness (the term used in place of mental disorder in these jurisdictions) is the
cause of suffering.
5 .1 W HY L OOK T O I NT E R NAT I ONAL EV IDENC E ON

M A I D M D-S U M C?
Since MAID MD-SUMC is not common in Canada, direct Canadian evidence on

its impact has not been published. As there are countries where it is permitted,
those experiences may provide insights about potential impacts and possible
safeguards. The Benelux countries allow people to seek EAS based on physical
or mental suffering alone, with no requirement of terminal illness or foreseeable
death. Switzerland and Germany also forego a “terminal illness” or “foreseeable
death” criterion, and requests can be based on physical or mental suffering,
but only assisted suicide is permitted in these jurisdictions. Thus, the legal
measures and clinical experiences in Belgium and the Netherlands — where
most permitted euthanasia and assisted suicide deaths for psychiatric conditions
(i.e., psychiatric EAS) have occurred — may provide important insights about
potential impacts and possible safeguards. These observations may also help
inform policy-makers about whether to leave unchanged, prohibit, or permit
more MAID MD-SUMC in Canada.
Aside from some sparse statistics indicating that psychiatric EAS is rare, relatively
little evidence is available from Switzerland; no cases of psychiatric EAS have
been reported in Luxembourg. There is one report from Germany describing
patients who received EAS from a German right-to-die organization; some of those
were psychiatric EAS (Bruns et al., 2016). However, the law in Germany prohibits
commercial organizations from assisting in suicides (Gov. of Germany, 2015).
Although the Working Group also reviewed information from jurisdictions

that have restricted assisted dying to those at end of life (including Quebec,
some U.S. states, and Victoria, Australia) and from those currently debating
assisted dying (e.g., United Kingdom), no evidence related to the practice of
MAID MD-SUMC exists in those jurisdictions.
5.1.1 Uses and Limits of International Data on Psychiatric EAS

The best available evidence for MAID MD-SUMC comes from Belgium and the
Netherlands. Nevertheless, the differences and similarities between the Benelux
countries and Canada must be taken into account in assessing the implications
of this evidence.
Canada is less densely populated than Belgium or the Netherlands, with different
governance structures and legal traditions. It has a more multicultural population,
a greater diversity of religions, multiple orders of government involved in the
governance and delivery of healthcare, and Indigenous Peoples whose views
must be considered and whom must be consulted during the development of
legislation. On the other hand, Canada, Belgium, and the Netherlands are
all wealthy countries, with similar GDP per capita, and they share a common
medical vocabulary based on the same scientific framework, evidence base,
diagnostic schemes, and treatment modalities.
While the Working Group was not tasked with reviewing the mental health or
legal systems in Belgium and the Netherlands, or these systems’ relationship
to the practice of psychiatric EAS, Working Group members do note that
striking differences exist among jurisdictions. They also note the importance
of avoiding either an uncritical extrapolation or a dismissal of Benelux data,
but rather to consider each potential impact and safeguard in light of specific
differences and commonalities among jurisdictions, including differences in
social background and cultural context. For example, most people in Belgium,
compared to Canada, are in closer reach of mental healthcare given the country’s
higher population density. Thus, requiring expert psychiatric treatment and
evaluation prior to psychiatric EAS may be less of a barrier in Belgium than it
might be in Canada. In Canada, which is less densely populated and has greater
disparities in healthcare access, that same safeguard may be more necessary to
avoid errors should MAID MD-SUMC become more widely available.
5 .2 THE I NT E RNAT I ONAL L E GAL L ANDSC APE
5.2.1 Legal Background

The Netherlands
Although the Termination of Life on Request and Assisted Suicide (Review Procedures)
Act was introduced in 2002 (Gov. of the Netherlands, 2002), in practice EAS had
been accepted in the Netherlands for decades prior to the 2002 Act (Rietjens
et al., 2009). As explained by Rietjens et al. (2009), the law “officially legalized
euthanasia, but in effect it mainly legalized an existing practice” that was already
legally protected through prior court decisions. There was also broad public
support for legal EAS (general EAS, not psychiatric EAS specifically) by the time
the Act was passed (Cohen et al., 2006). Therefore, there was minimal debate
about the legalization of EAS compared to some other countries at the time of
legislation because there was existing case law (e.g., Griffiths, 1995). In 1994,
case law established that EAS for mental suffering is permissible (Griffiths, 1995).
The Act legally protects the practice of EAS when a physician has complied
with the Act’s due care criteria. The due care criteria encompass both eligibility
criteria and procedural safeguards. Section 2(1) of the Act outlines the due
care criteria, and, as translated in the RTE Code of Practice, states that “the
physician must:
(a) [b]e satisfied that the patient’s request is voluntary and well-considered;
(b) be satisfied that the patient’s suffering is unbearable, with no prospect of
improvement;
(c) have informed the patient about his/her situation and prognosis;
(d) have come to the conclusion, together with the patient, that there is no
reasonable alternative in the patient’s situation;
(e) have consulted at least one other, independent physician, who must see
the patient and give a written opinion on whether the due care criteria
set out in (a) to (d) have been fulfilled;
(f) have exercised due medical care and attention in terminating the
patient’s life or assisting in his suicide.”
(RTE, 2015b)
There are also reporting requirements in the Netherlands, whereby the physician
must inform the RTEs after the fact about an EAS (Gov. of the Netherlands,
2002). The RTEs release an annual summary report of EAS cases. The RTEs are
unique among jurisdictions in publishing reports of EAS cases they consider
particularly instructive or controversial.
Belgium
While Belgium does not have the same history of EAS as the Netherlands,
“prosecutions were unusual and, generally speaking, the practice of euthanasia
was tolerated” by 2002 (Cohen-Almagor, 2009). Public acceptance of EAS, as
measured by a survey of the Belgian public ranking their acceptance of EAS
from 1 to 10 (1 meaning EAS was “never justified,” and 10 meaning it was “always
justified”), was fairly high prior to the passing of their law, having increased
by 69% between 1981 (when the mean surveyed acceptance rate of EAS was
3.5) and 1999 (when the mean surveyed acceptance rate of EAS was 6.0), as
calculated by the percentage difference in mean survey acceptance rates on a
scale of 1 to 10 (Cohen et al., 2006).
The Belgian Act on Euthanasia (2002) contains eligibility criteria and procedural
safeguards that must be followed when EAS is to be performed, and, similar
to the Dutch Act, has always included suffering of either a physical or mental
nature as grounds for an EAS request (Gov. of Belgium, 2002). With respect
to eligibility requirements, the Belgian law states that physicians who carry out
EAS are not committing a crime, provided they ensure that:
• “the patient has attained the age of majority or is an emancipated minor, and
is legally competent and conscious at the moment of making the request;
• the request is voluntary, well-considered and repeated, and is not the result
of any external pressure;
• the patient is in a medically futile condition of constant and unbearable
physical or mental suffering that can not be alleviated, resulting from a serious
and incurable disorder caused by illness or accident”18 with no reasonable
treatment alternatives or therapeutic perspectives.
(Gov. of Belgium, 2002).
Procedural safeguards include the consultation of a physician, independent

from the physician initially evaluating the request, about the serious and
incurable nature of the condition (Gov. of Belgium, 2002). In cases where
death is not foreseeable:
• a third physician (second consultant), who is an expert in the disorder in
question, is required to consult; and,
• a one-month waiting period between the written request and the act of EAS
is required.
(Gov. of Belgium, 2002)
As in the Netherlands, the physician reports the EAS after the fact, to a
retrospective review committee (Gov. of Belgium, 2002).
Luxembourg
Luxembourg modelled its EAS Act largely on the Belgian Act (Nys, 2017). The
eligibility requirements for EAS are the same in Belgium and Luxembourg.
However, the procedural safeguards in the Belgian Act that apply when a patient’s
death is not foreseeable were not adopted in the Luxembourg Act (i.e., a third
expert consultation and one-month waiting period between request and EAS)
(Gov. of Luxembourg, 2009).
Luxembourg also has reporting requirements. Every time a physician performs

EAS, an official declaration document must be obtained from the Commission
Nationale de Contrôle et d’Evaluation (CNCE), completed by the physician,
and sent back to the CNCE for review (Gov. of Luxembourg, 2009). The CNCE
is legislated to publish a statistical report on the information collected from
the declarations every two years.
Switzerland
In Switzerland, the law allows for assisted suicide (not euthanasia) if the person
assisting does so for unselfish reasons (Gov. of Switzerland, 1942).
The 2006 Swiss Haas case involved a person who suffered from bipolar affective
disorder for about 20 years and who had twice previously attempted suicide
(European Court of Human Rights, 2011). Haas petitioned the Swiss government
to allow assisted suicide on the basis of his mental disorder (European Court
of Human Rights, 2011). The Swiss Federal Supreme Court held that it was not
against the law to provide a lethal prescription to people with mental disorders,
provided certain eligibility criteria were met. These additional eligibility criteria
included a thorough psychiatric evaluation with a specialist to establish whether
the decision is “autonomous and all-encompassing,” such that:
• the patient has capacity;
• the request does not stem from a treatable condition; and
• the request is made without undue influence.
(Black, 2012, 2014)
Germany
Similar to Switzerland, as of 2015, German law allows for assisted suicide (not
euthanasia) if the person assisting does not do so with a commercial intent (Gov.
of Germany, 2015). Close relatives or other people close to the person seeking
an assisted death are exempt from criminal liability (Gov. of Germany, 2015).
5.2.2 Laws and Guidelines for Psychiatric EAS in

Benelux Countries and Switzerland
Benelux Countries
The eligibility criteria, procedural safeguards, and reporting requirements
that must be met by a physician in the Benelux countries for psychiatric EAS
are summarized in Table 5.1.
The Dutch Act contains few details on the actual procedures that patients and
physicians should follow when dealing with an EAS request; the Dutch RTEs have
therefore published a Code of Practice to help patients and physicians request
and carry out EAS in a manner that complies with the Act (RTE, 2015b). The
Code of Practice is a “summary of the considerations that the committees have
published in their annual reports and findings in recent years” (RTE, 2015b).
The Dutch Psychiatric Association (Nederlandse Vereniging voor Psychiatrie,
or NVVP) has published and revised guidelines on the role of psychiatrists who
receive EAS requests from patients with psychiatric disorders (Berghmans et
al., 2009). The Flemish Association for Psychiatry (Vlaamse Vereniging voor
Psychiatrie, or VVP) also recently published guidelines (VVP, 2017); however,
these are not included in Table 5.1 as it is unclear how these Belgian guidelines
will influence clinical practice going forward. Before the release of these
guidelines, Belgian psychiatrists looked to the NVVP guidelines. Although
the guidelines suggested by the RTE Code of Practice and the NVVP are not
official laws, they are included in Table 5.1 as a separate column, as they can
inform RTE deliberations (Onwuteaka-Philipsen et al., 2017).
While consultation with an additional physician (or physicians) is a safeguard in

Benelux countries, confirmation or agreement with the requesting physician is
not. The consultation procedural safeguard involves the consulting physician
seeing the patient and giving a written statement of judgment on whether the
person making the request meets eligibility requirements (RTE, 2015b).
The Dutch consultant’s written report is provided to the RTE (RTE, 2015b); the
Belgian consultant’s opinion is conveyed through the report of the physician
performing the EAS (Gov. of Belgium, 2002). As explained below, while the
Dutch RTEs publish instructive or controversial cases (e.g., they published all
psychiatric EAS cases reported in 2013) (RTE, 2014), the Belgian Commission
fédérale de Contrôle et d’Évaluation de l’Euthanasie (CFCEE) does not make
any of their cases public, even in anonymized form.
Table 5.1
Stipulations for Psychiatric EAS in the Netherlands, Belgium, and Luxembourg
Country
Netherlands Belgium Luxembourg
Stipulation
Suggested
Required Required Required
by RTE or
by Law by Law by Law
NVVP
Request must be voluntary and well
X (X) X X
considered
Physician must be satisfied that patient’s
suffering is unbearable, with no prospect for X (X) X X
improvement
Physician must inform patient about
X (X) X X
situation, prognosis
Physician must have come to the conclusion,
along with the patient, that there is no X (X) X
reasonable alternative
Unless the patient objects, the physician
must discuss the request with the patient’s X X
representative and/or family members
Patient’s case must be assessed by
X X* X* X
independent consulting physician
Consultant must be an expert in the
X X
disorder or disease causing suffering
One-month waiting period between
request and EAS when death is not X
imminent
EAS deaths must be reported to an oversight
X (X) X X
committee
Statistical data and information on
implementation are regularly reviewed and X (X) X X
reported publicly (annually or biannually)
Source: Gov. of the Netherlands, 2002; Gov. of Belgium, 2002; Berghmans et al., 2009;
Gov. of Luxembourg, 2009; RTE, 2015b, 2016)
Bolded stipulations relate directly to cases where the patient’s death is not foreseeable (for countries
that rely on this criterion). Brackets indicate that these criteria are already part of the Dutch law.
Acronyms in table: euthanasia and assisted suicide (EAS), Nederlandse Vereniging voor Psychiatrie
(NVVP), and Regional Euthanasia Review Committees (RTE).
* If death is not foreseeable in Belgium, two additional independent physicians who are experts in
the disorder must be consulted. Only one consulting physician is required in the Netherlands and
Luxembourg by law, although the Dutch RTE Code of Practice recommends consulting a regular,
independent physician, as well as an independent psychiatrist for psychiatric EAS requests.
To help consulting physicians, both the Netherlands and Belgium have established
specialized support services (Van Wesemael et al., 2009a). The Royal Dutch
Medical Association (KNMG) trains a cohort of physician-consultants through the
Support and Consultation on Euthanasia in the Netherlands (SCEN) program
(Brinkman-Stoppelenburg et al., 2014). In Belgium, the Life End Information
Forum (LEIF) was established in 2003 to help physicians deal with EAS requests
(Van Wesemael et al., 2009a; Van Wesemael et al., 2009b). Unlike the Dutch
SCEN, which was founded by the KNMG, LEIF was founded by “individual
professionals with experience in palliative care and the association Right to
Die with Dignity” (Van Wesemael et al., 2009a).
While differing in organizational structure, regulation, and origins, as well as

in mandate (LEIF has a broader consultation role by providing information on
all end-of-life care), both SCEN and LEIF require the same number of training
hours for physicians (approximately 23 hours) (Van Wesemael et al., 2009a).
Switzerland
In Switzerland, two main groups serve people who request assisted suicide: EXIT
and DIGNITAS (other right-to-die groups include Lifecircle/Eternal Spirit).
These groups have additional requirements above those set out in legislation.
For example, EXIT requires that those requesting assisted suicide whose sole
underlying medical condition is a mental disorder have a hopeless prognosis,
or have unbearable symptoms, or have unacceptable disabilities (EXIT, 2016);
the individual requesting an assisted suicide judges what is unacceptable,
along with two independent expert opinions and the verdict of the Society’s
Ethics Commission (EXIT, 2016). DIGNITAS, which accepts both Swiss and
non-Swiss cases, requires that, as a prerequisite for the preparation of an
assisted suicide, the person “must have a disease that will lead to death, and/
or [have] an unendurable incapacitating disability, and/or [be] in unbearable
and uncontrollable pain” (DIGNITAS, 2017).
5.2.3 Practitioner and Public Opinions on Psychiatric EAS

in the Netherlands
A 2010 Dutch survey revealed wide support for the eligibility criteria and
procedural safeguards for EAS in general among physicians (n=793), nurses
(n=1,243), and the public (n=1,960) (Kouwenhoven et al., 2012). Specifically,
88% of physicians, 77% of nurses, and 64% of the public agreed with the
requirement of a patient request, and 71% of physicians, 64% of nurses, and 48%
of the public agreed with the absence of a requirement about life expectancy.
There was less support for psychiatric EAS (which in the survey included
early dementia cases) — 35 to 36% of healthcare practitioners and 28% of
the public found EAS for chronic depression acceptable. In the case of severe
dementia, 33% of physicians, 58% of nurses, and 77% of the public approved
of performing EAS based on an advance directive (for further discussion,

see The State of Knowledge on Advance Requests for Medical Assistance in Dying)
(Kouwenhoven et al., 2012). Another survey of Dutch physicians (n=1,456)
found that 34% could conceive of granting psychiatric EAS in general, 40% for
patients with early-stage dementia, and 29 to 33% for patients with advanced
dementia (Bolt et al., 2015).
The Third Review of the Dutch Act (Derde evaluatie — Wet toetsing levensbeeindiging
op verzoek en hulp bij zelfdoding) surveyed 500 psychiatrists about their experiences
with, and views on, psychiatric EAS requests, and 207 responded (Onwuteaka-
Philipsen et al., 2017). Thirty-two percent (66 of 207 respondents) had previously
granted and/or refused a request for psychiatric EAS. These 66 respondents
were asked additional questions about the last request they had granted or
refused. The percentage of psychiatrists who had not performed EAS but would
conceivably do so decreased from 47% in 1995 to 37% in 2016. Of those who
had never performed EAS in 2016, 63% thought it inconceivable that they
would ever perform EAS, and, out of this 63%, 3% would not refer a request
to another doctor. Of the psychiatrists who thought it was inconceivable they
would perform EAS, 4% were in favour of a general prohibition of EAS, and
7% were in favour of prohibiting psychiatric EAS. When surveyed about their
reason not to perform EAS in the last request they evaluated (n=66), 75% stated
the primary reason was that due care requirements were not met (Onwuteaka-
Philipsen et al., 2017).
These data are similar to a recent Canadian survey of psychiatrists (n=528),

which found that 72% supported MAID, at least for some situations, while 29%
supported MAID MD-SUMC (Rousseau et al., 2017).
Dutch psychiatrists were also asked about arguments that support permitting
or prohibiting psychiatric EAS (Onwuteaka-Philipsen et al., 2017). Arguments
psychiatrists mentioned that support psychiatric EAS included: it is unfair to
exclude this group when it is possible they fulfil the due care criteria; psychiatric
suffering might be worse than somatic suffering; the right to self-determination;
offering a dignified end of life to patients who otherwise might die by suicide;
and the conviction that seriously considering a request for EAS is part of the
responsibility of a physician. Arguments psychiatrists mentioned that support
prohibiting psychiatric EAS included: the risk of countertransference (a therapist
transferring emotions to a patient in therapy); conflicts between treatment
goals and termination of life; interpretation of due care requirements in people
with psychiatric disorders, including doubts about the extent to which the
request of a psychiatric patient can be voluntary and well-considered; and the
question of whether one should consider granting an EAS request when the
quality of mental healthcare is not sufficient (Onwuteaka-Philipsen et al., 2017).
The Third Review of the Dutch Act also discussed EAS for people with dementia.
In a survey of Dutch citizens, 60% agreed that people with dementia should
qualify for EAS, 24% were neutral, and 16% disagreed (Onwuteaka-Philipsen
et al., 2017). Physicians were also surveyed about the conceivability that they
would perform EAS for early dementia (i.e., where the patient has capacity);
in 2016, 52% of general practitioners (n=607), 25% of medical specialists
(n=331), and 53% of geriatricians (n=209) could conceive of providing EAS
for early dementia.
5.2.4 Practitioner and Public Opinion on Psychiatric EAS in Belgium

A Belgian survey of psychiatric nurses (n=627) showed that 84% support EAS
for people with psychiatric disorders (including dementia) who experience
unbearable mental suffering (De Hert et al., 2015). There are, however, no
Belgian survey data relating to the views of physicians and the public. The VVP
states that it is currently impossible to obtain a consensus from their member
psychiatrists as to whether psychiatric EAS should be permissible, as members
were strongly divided (VVP, 2017).
5 . 3 S O UR C E S A ND QU AL I T Y OF E V I DE NC E R ELATING
TO P S YC HI AT RI C E AS
In Belgium and the Netherlands, psychiatric EAS cases comprise a small

proportion (0.5 to 3%, depending on the year) of the total number of EAS
cases, but are becoming more frequent (Dierickx et al., 2017; RTE, 2017b).
With respect to EAS deaths overall in Belgium and the Netherlands, there
are two primary sources of statistics. First, the CFCEE in Belgium and the
RTEs in the Netherlands (both review bodies) publish reports; the RTEs
also publish summaries of selected cases. Second, estimates of the total cases
are published in periodic studies (approximately every five to six years),
conducted by independent researchers commissioned by the government
in the Netherlands and supported by a federal research funding agency in
Flanders (the Dutch-speaking region of Belgium; no similar studies are done
in the French-speaking region). These studies also contain excerpts that are
published in major international journals (e.g., Chambaere et al., 2015; van der
Heide et al., 2017). Flanders and the Netherlands have shown an increase in
the overall rate of EAS since 2002, accounting for 1 in about 25 deaths (4.5%
in the Netherlands in 2015, and 4.6% in Flanders in 2013) (Chambaere et al.,
2015; van der Heide et al., 2017).
In Luxembourg, 34 EAS cases were declared between 2009 and 2014, of which
none were psychiatric EAS, but 6 cases involved people with neurodegenerative
disorders (CNCE, 2015). In Switzerland, psychiatric EAS does occur but only
limited data are available, since only cases with depression as the sole underlying
medical condition are reported. Given that data are not available for the entirety
of psychiatric EAS practices in these jurisdictions, this chapter will focus on
Belgium and the Netherlands.
5.3.1 Sources of Evidence Specific to Psychiatric EAS

Most of the data on psychiatric EAS in Belgium come from three sources. The
first is a study of 100 consecutive requests for psychiatric EAS reported by a
research group (Thienpont et al., 2015). The 35 cases of psychiatric EAS that
were carried out (from a total of 100 requests) mentioned in Thienpont et al.
(2015) likely represent a substantial proportion of the cases of psychiatric EAS
between 2007 and 2011 in Belgium, although the CFCEE does not provide
specific data on psychiatric EAS during this period (but the classification of
neuropsychiatric disorders which include psychiatric EAS cases, and those stemming
from neurodegenerative disorders, did not exceed 100 cases for the same time
period) (Claes et al., 2015). The group also published a qualitative analysis
of testimonials written by 26 of these patients (Verhofstadt et al., 2017). The
second source, Dierickx et al. (2017), published a summary of psychiatric and
dementia cases from 2002 to 2013; they used official data from the CFCEE
database. The third source is made up of Flemish studies that also provide
some disorder-specific information (e.g., Dierickx et al., 2015).
In the Netherlands, in addition to the every-five-year national studies — two

of which survey Dutch psychiatrists (Groenewoud et al., 1997; Onwuteaka-
Philipsen et al., 2017) — and resulting papers, the RTEs make public the case
summaries of those they deem educational or controversial. Much of what we
now know about psychiatric EAS at the patient level comes from these reports.
Summaries of many Dutch psychiatric EAS cases have been published. As a

result, Kim et al. (2016) were able to analyze 78% (66 of 85 cases) of all known
cases from 2011 to early 2014.19 These case summaries may contain much more
information than the physicians’ written reports because, in controversial
practices such as psychiatric EAS, the RTEs may conduct follow-up interviews
with the involved physicians (thus, some reports can be 12 to 13 single-spaced
pages, though many are approximately 2 to 3 pages) (RTE, 2017b). These case
summaries are based on reports written around the time of the EAS, compared
to surveys of psychiatrists in national studies, which require recollection of
events that sometimes occurred years before. According to the RTEs, “the joint
19 In early 2014, for the years 2011 to 2014, there were 85 reported cases of psychiatric EAS
mentioned on the RTE website (https://www.euthanasiecommissie.nl/oordelen/): 13 cases in
2011, 14 in 2012, 42 in 2013, and 16 in 2014 (the final number for that year was not available
at the time). Sixty-six of those cases were published online.
annual reports of the [RTEs] and the findings published on their website give
an impression of how the committees apply and interpret the statutory due
care criteria for euthanasia” (RTE, 2015b).
The Working Group notes that there are limitations associated with conclusions
from the RTE case studies. Case summaries are comprised of reports submitted
by the physician associated with the EAS, request as well as RTEs’ follow-up
communications with them (written feedback as well as face-to-face interviews
in some cases), and therefore may not include all details of how the physician
evaluated the due care criteria.
5.3.2 Jurisdictions Not Discussed in Detail Due to Limited Data

In addition to Belgium and the Netherlands, psychiatric EAS has occurred
in Germany and Switzerland. In Germany, a recent case series of 117 assisted
deaths from 2010 to 2013 performed by Sterbehilfe Deutschland (Euthanasia
Germany) showed that 17 people (15%) “had a predominant psychiatric
diagnosis,” and 9 people (8%) had no mental disorder or medical condition;
83 cases (71%) involved women (Bruns et al., 2016).
In Switzerland, among 43 cases of assisted suicide performed by EXIT in the

Basel region, 6 people had a psychiatric diagnosis (mainly depression) (Frei
et al., 1999; Frei et al., 2001). Among 331 EXIT cases in the Canton of Zurich,
9 people (2.7%) had depression or schizophrenia between 1990 and 2000
(Bosshard et al., 2003). Gauthier et al. (2015) found 14 cases (1.5%) of non-
Swiss residents with a mental disorder receiving assisted suicide in the Canton
of Zurich from 2008 to 2012. More recent data indicate that depression was
reported as the underlying disease in 3% of assisted suicide cases among Swiss
residents from 2010 to 2014 (0.8% of cases reported dementia), with no other
psychiatric conditions being identified in the report (FSO, 2014).
5 . 4 P S YC HI ATR IC E AS : F RE QU E NCY AND TR ENDS IN

THE N E THE R L ANDS AND B E L GI U M
In the annual Dutch RTE reports and the Belgium CFCEE reports, EAS cases
are described by the nature of the disease that causes suffering; the categories
psychiatric disorders and dementia are both used. As the Working Group chose
to use the DSM-5 definition of mental disorders in this report, the categories
psychiatric disorders and dementia are both considered in this section. However, the
focus of much of the international evidence presented in the remainder of this
chapter is on psychiatric EAS cases involving people diagnosed with psychiatric
disorders excluding dementia (hereafter the use of psychiatric EAS refers to
requests and cases not stemming from dementia, unless otherwise noted).
The reason for this is two-fold. Most of the published academic studies that
have analyzed these data have focused principally on the cases classified under
psychiatric disorders (e.g., Thienpont et al., 2015; Kim et al., 2016). Additionally,
some of the international dementia cases would not be classified as MAID
MD-SUMC, since those requesting EAS did not have capacity (these types
of cases are discussed in The State of Knowledge on Advance Requests for Medical
Assistance in Dying).
In the Netherlands, some of the cases categorized as psychiatric disorders or

dementia also involved an underlying physical disorder. In these cases, however,
the suffering was judged to be mainly due to psychiatric disorder(s) or dementia
(RTE, 2017b).
5.4.1 The Netherlands

In the 1990s, psychiatric EAS was rare. It was estimated to occur 2 to 5 times
per year in 1995, accounting for 0.1 to 0.3% of all EAS cases; the total number
of reported EAS cases in 1995 was 1,463 (Groenewoud et al., 1997; Rurup et al.,
2008). This continued until about 2011, after which the rate began to rise so
that, by 2017, psychiatric disorders accounted for about 1% of the total number
of EAS deaths (RTE, 2018a). In terms of number of requests, Dutch physicians
received an estimated 320 psychiatric EAS requests in 1995, with 2 to 5 cases
performed that year (approximately 0.6 to 1.5% acceptance rate); in 2008 there
were approximately 500 requests and 30 cases of psychiatric EAS performed
(approximately 6% acceptance rate); and in 2016 there were approximately
1,100 requests and 60 cases of psychiatric EAS performed (approximately 5%
acceptance rate) (Onwuteaka-Philipsen et al., 2017).
The number of psychiatric EAS cases (n=83) increased to 1.2% of all EAS cases
in 2017, from 0.77% in 2014 (n=41) (RTE, 2018a) (Figure 5.1). When dementia
cases are also included (n=169),20 together the two categories comprise 3.8% of
all EAS cases, increasing from 2.3% in 2014 (n=122) (RTE, 2018a) (Figure 5.1).
20 In 2017, the Dutch RTEs began including two dementia reporting categories: dementia in the
initial phase, and farther advanced dementia. For comparison with past years, these data were
grouped and termed dementia for this report.
7,000 4.5
4.0
6,000
3.5
Percentage of Total EAS Deaths (%)

5,000
Total Number of EAS Deaths
3.0
4,000 2.5
3,000 2.0
1.5
2,000
1.0
1,000
0.5
0 0
2014 2015 2016 2017
Year
Dementia
Psychiatric Disorders Excluding Dementia Percentage of EAS Cases that Are Psychiatric or Dementia
Other Diagnoses Percentage of EAS Cases that Are Psychiatric
300
250
Number of Psychiatric EAS Deaths
200
150
100
50
0
2014 2015 2016 2017
Year of Reporting
Dementia
Psychiatric Disorders Excluding Dementia
Data Source: RTE, 2015a, 2016, 2017b, 2018a
Figure 5.1
Reported EAS Cases in the Netherlands, 2014 to 2017
Each year EAS cases are reported to RTEs in the Netherlands, and published in annual reports. In 2017,
RTEs began including two dementia reporting categories; dementia in the initial phase, and farther
advanced dementia. For comparison with past years, these data were grouped and termed dementia
for this report.
5.4.2 Belgium
There were 6 reported cases that identified neuropsychiatric conditions
(“affection neuropsychiatrique”) as the underlying medical condition in Belgium
in 2004 (2.0% of all EAS cases), increasing to 40 cases identifying mental and
behavioural disorders as the underlying medical condition (of which 14 of these
cases were dementia) in 2017 (1.7% of all EAS cases) (CFCEE, 2006, 2018a).
Between 2014 and 2017, both the total number and percentage of all EAS
cases that were psychiatric, including dementia, decreased (Figure 5.2). The
number of mental and behavioural disorder EAS cases, excluding dementia
(n=26), decreased to 1.1% of all EAS cases in 2017, from 2.3% in 2014 (n=45)
(CFCEE, 2018a) (Figure 5.2). When dementia cases are also included (n=40),
together the two categories comprise 1.7% of all EAS cases in 2017, decreasing
from 3.2% in 2014 (n=61) (CFCEE, 2018a) (Figure 5.2).
In a chronological study of reported Belgian psychiatric EAS cases from 2002

to 2013 by Dierickx et al. (2017), one or more psychiatric disorders were
the cause of suffering in 117 requests. Over the 11-year range, this number
rises to 179 requests if dementia cases are included. Of these 179, diagnoses
included mood disorders (n=83), dementia (n=62), as well as mood disorders
accompanied by another psychiatric disorder (n=12); 77% of the 117 psychiatric
disorder cases (n=88), and 58% (n=36) of the dementia cases involved women
(Dierickx et al., 2017).
5.4.3 Increase in Psychiatric EAS Cases in

In the Netherlands, there has been an increase through time in both the number
of psychiatric EAS cases (excluding dementia), as well as the percentage of total
EAS deaths comprising psychiatric cases (excluding dementia) (Figure 5.1)
(Chabot, 2017; RTE, 2018a). In Belgium, while the total yearly number of
psychiatric EAS cases (excluding dementia) has increased since 2004, in recent
years (2014 to 2017) both the number and percentage of total EAS deaths
comprising psychiatric cases (excluding dementia) has decreased (Figure 5.2)
(CFCEE, 2018a; Dierickx et al., 2017).
2500 3.5
3.0
2000
Percentage of Total EAS Deaths (%)

2.5
Total Number of EAS Deaths
1500
2.0
1.5
1000
1.0
500
0.5
0 0
2014 2015 2016 2017
Dementia Year
Mental and Behavioural Disorders Percentage of EAS Cases that Are Mental or Behavioural Disorders
Excluding Dementia Including Dementia
Other Diagnoses Percentage of EAS Cases that Are Mental or Behavioural Disorders
70
60
Number of Psychiatric EAS Deaths
50
40
30
20
10
0
2014 2015 2016 2017
Year of Reporting
Dementia
Mental and Behavioural Disorders Excluding Dementia
Data Source: CFCEE, 2018a
Figure 5.2
Reported EAS Cases in Belgium, 2014 to 2017
Each year EAS cases are reported to the CFCEE in Belgium, and published in reports every two years.
The overall increase in the total number of psychiatric EAS cases (excluding
dementia) since 2002 has stimulated discussion (Claes et al., 2015; Dierickx et
al., 2015, 2016; Chabot, 2017; Dierickx et al., 2017). This increase may reflect
a normal process of change, by which certain groups (both patients and their
physicians) explore and adapt to new legal options. For example, a gradual
increase was observed for other types of EAS cases after the introduction
of the Belgian Act on Euthanasia: patients with a diagnosis of cardiovascular
disease, those with a college or university education (Dierickx et al., 2015),
non-terminally ill patients (Dierickx et al., 2016), and older patients (Dierickx
et al., 2015, 2016) all increasingly sought EAS. Some have argued that part
of the increase may be due to the media reporting of noteworthy cases of
psychiatric EAS (including individuals with dementia), such as the death of
Hugo Claus, who had early-stage Alzheimer’s (Van Brussel & Carpentier, 2012).
In Belgium, reported cases of people who were not expected to die in the near
future increased, from 8.1% (n=19) of all EAS cases in 2003 to 14.7% (n=266)
in 2013 (Dierickx et al., 2016). In the Netherlands, however, this explanation
does not account for the increase in psychiatric EAS occurring later than the
increases in other types of EAS. All types of EAS had been legally permitted
since 2002, although in practice EAS had been accepted for decades prior, and
psychiatric EAS accepted since the 1994 Chabot case.
5.4.4 The Increasing Role of the End-of-Life Clinic

In the Netherlands, there has been an increase in psychiatric EAS cases performed
by the End-of–Life Clinic (Levenseindekliniek), an organization that does not
treat patients for illnesses but whose mission is to evaluate and provide EAS
to those whose doctors have declined to perform the procedure (Box 5.1).
The number of EAS cases the End-of-Life Clinic performs is published in the
annual RTE reports and by the Clinic itself. In 2015, 60% of Dutch psychiatric
EAS cases were performed by this clinic, and in 2016, 75% (46 out of 60 cases)
(Chabot, 2017). In contrast, the Clinic performs approximately 5 to 8% of the
total number of EAS cases in the country (RTE, 2015a, 2016, 2017b).
Box 5.1
End-of-Life Clinic
In the Netherlands, the End-of-Life Clinic (Levenseindekliniek) was established in

2012 by the country’s leading euthanasia advocacy organization to assess, and if the
case qualified, provide EAS to people whose request was initially denied by their own
physician (Levenseindekliniek, n.d.-b). As a result, physicians offering EAS through
the Clinic are always new to the patient.
The Clinic is subject to the same legal criteria as all other Dutch EAS providers, and
as such all requests are evaluated to see whether they meet due care criteria. The
evaluation, as described by Snijdewind et al. (2015), proceeds as follows: “When
authorized by the patient, the clinic obtains the medical files from the treating
physician or physicians. On the basis of the application form and medical files, a
nurse makes a first classification. Some applications are rejected. A mobile team,
consisting of a nurse and physician working for the clinic, further assesses the others
[...] If a case is further assessed, the mobile team contacts the treating physician
to discuss their reasons for rejecting the request and visits the patient (most often
multiple times). In this stage, a case can be rejected if it seems unable to meet the
due care criteria. If the mobile team decides that the due care criteria can be met, a
physician from [SCEN] specifically trained to give independent consultations about
requests for [EAS] is consulted, as is required by Dutch law. A meeting then follows
with the mobile team, another physician working for the clinic, and a lawyer. If all
those participating in the meeting agree that the due care criteria can be met, a
request for [EAS] is granted. During the entire process, the patient can withdraw his
or her request at any time.”
One-third of all applicants to the Clinic are psychiatric patients (Levenseindekliniek,

n.d.-a). In its first year of operation, 5% of EAS requests (6 of 121) from individuals
with a psychiatric condition were granted (Snijdewind et al., 2015).
5 .5 C HA RAC T E RI S T I C S OF I NDI V I DU ALS WH O

R E Q U E S T /RE C E I V E P S Y CH I AT R IC EAS

More than Twice as many Women than Men Receive Psychiatric EAS
A review of 66 Dutch psychiatric EAS case summaries from 2011 to early 2014,
representing 78% of all psychiatric EAS cases reported during that period,21
found that people receiving EAS for psychiatric disorders were mostly women
(70%, n=46), of diverse ages, and with complex as well as chronic psychiatric and
medical histories (Kim et al., 2016). The gender disparity in psychiatric EAS cases
contrasts with the ratio of 43% women to 57% men among all EAS recipients
in the Netherlands (Onwuteaka-Philipsen et al., 2012). This finding of a
preponderance of women in psychiatric EAS cases is consistent with previous
studies from the Netherlands (Groenewoud et al., 1997; Groenewoud et al., 2004).
A Wide Diversity of Conditions Qualify for Psychiatric EAS

The wide diversity of psychiatric disorders cited in these psychiatric EAS
cases is notable. Some people had a chronic psychotic disorder (with active
hallucinations and delusions) while others had a more recently diagnosed
condition: one patient received EAS 12 months after her husband’s death, for
prolonged grief disorder. A consultant reported that this woman felt her life
had no meaning after her husband’s death and yet “did not feel depressed
at all. She ate, drank, and slept well. She followed the news and undertook
activities” (Kim et al., 2016).
Depressive disorders were the primary psychiatric condition presenting in 36 of

66 cases (55%) (Kim et al., 2016). Psychotic disorders were not unusual, with 17
of 66 (26%) people having some form of psychotic condition (schizophrenia,
schizoaffective disorder, psychotic depression, and other psychotic disorders).
PTSD-related and other anxiety disorders were prominent (28 of 66 people,
or 42%). Four people (3%) had cognitive impairment — one of whom had a
legal guardian at the time of their EAS (but was judged “competent” by two
independent consultants, including one psychiatrist). Four women (3%) had
chronic eating disorders with borderline personality disorders. Two people
had autism spectrum diagnoses and two had prolonged grief. Fifty-two percent
had personality-related problems (34 of 66). Fifty-two percent had attempted
suicide in the past (34 of 66), and 80% had been hospitalized at some point
during their life (53 of 66). Social isolation or loneliness were mentioned in
56% of cases (37 of 66) (Kim et al., 2016).
21 From 2011 to early 2014, there were 85 reported cases of psychiatric EAS mentioned on the
RTE website (https://www.euthanasiecommissie.nl /oordelen/): 13 cases in 2011, 14 in 2012,
42 in 2013, and 16 in early 2014 (the final number for that year was not available at that time).
Sixty-six of those cases were published online.
In a study of the first year of the End-of-Life Clinic’s operation that compared
granted (n=162) and rejected requests (n=300), individuals who had their
requests rejected were more often single (58%) than married or living together
(20%), or widowed (21%) (Snijdewind et al., 2015). Individuals who had their
requests rejected were also more often childless (50%), than those who had one
child (13%) or more than one child (37%). Note that this study included all
requests received, not just those for psychiatric EAS (Snijdewind et al., 2015).
Based on data from the 1996 national Dutch study, Groenewoud et al. (1997)
found that mood disorders were common diagnoses associated with psychiatric
EAS requests; 64% of the sampled requests received by psychiatrists had
diagnoses of a personality disorder (130 of 202 people), and approximately 2 to
5 psychiatric EAS cases were granted per year out of approximately 320 requests
per year from psychiatric practice. More recently, data from a 2016 survey of
Dutch psychiatrists showed they received approximately 1,100 requests for EAS
from psychiatric patients, of which an estimated 60 were granted (Onwuteaka-
Philipsen et al., 2017). In 2016, psychiatrists reported they received on average
roughly one EAS request per year each. Among refused psychiatric EAS requests
(n=66), 59% had a personality disorder diagnosis, 50% had an affective disorder,
17% had a psychotic disorder, and 9% were diagnosed with autism spectrum
disorder (patients could have more than one diagnosis) (Onwuteaka-Philipsen
et al., 2017).
Age
In 2017, within the dementia and psychiatric disorders categories (reported
together in the latest data release), the highest number of psychiatric EAS cases,
including dementia, reported to the RTEs involved people 80 to 90 years old
(n=63) and 50 to 60 years old (n=16) (RTE, 2018a).
5.5.2 Belgium
Belgian Findings Are Similar to the Netherlands
In the most recent CFCEE report covering EAS cases from 2014 to 2017,
36% of psychiatric EAS cases (73 of 201) involved individuals identified as
having mood disorders (e.g., depression, bipolar disorder), 30% (60 of 201)
involved individuals with dementia, and 3.8% (23 of 201) involved individuals
with personality disorders (CFCEE, 2018a). In a Belgian case series of 100
consecutive requests for psychiatric EAS, 58 individuals (58%) presented
with “treatment-resistant depression” (48 with major depressive disorder and
10 with bipolar disorder), 14 with schizophrenia or other psychotic disorders,
13 with PTSD, 11 with anxiety disorders, 10 with eating disorders, 10 with
substance use disorders, 9 with somatoform disorders, 7 with Asperger syndrome
(with potentially 12 additional cases after follow-up psychiatric evaluations),
1 with attention deficit hyperactivity disorder, 7 with obsessive compulsive

disorders, 7 with dissociative disorders, and 6 with complicated grief, among
others (some had more than one disorder) (Thienpont et al., 2015). Fifty percent
of those making a request had personality disorders (Thienpont et al., 2015).
A similar diversity of conditions was seen in the Netherlands (Kim et al., 2016).
Across 100 consecutive Belgian requests for psychiatric EAS, the majority
(77%) came from women (Thienpont et al., 2015), which is consistent with the
Dierickx et al. (2017) study of cases reported in the CFCEE database from 2002
to 2013. However, with respect to dementia cases in Belgium, the gender of
those requesting was more balanced; 58% of cases involved women (Dierickx
et al., 2017). The most recent CFCEE report did not provide gendered data
relating to psychiatric EAS requests, but, in 2017, the ratio of women to men
requesting all EAS was roughly equal: 51% of requests were from men (n=1,175)
and 49% of requests were from women (n=1,134) (CFCEE, 2018a).
Of the 100 people included in the Thienpont et al. (2015) study, 26 provided
written testimonies to their doctors, which were qualitatively analyzed (Verhofstadt
et al., 2017). Themes related to a patient’s suffering were identified and included
lack of hope of getting better given previous treatment failures, feeling like
“there’s nothing left to work on” in therapy, and no quality of life (Verhofstadt
et al., 2017). Some patients explained why, after receiving approval for EAS,
they changed their minds: “[T]he people around you cannot believe that
you want to die, because you’re looking so good […] So when I finally got
the permission to die, that was a huge relief […] I have to admit that since
[the approval], I’m experiencing better moments and I’m also in doubt now”
(Verhofstadt et al., 2017).
Other themes included lack or loss of social supports or understanding from

important others; mourning over the death of important others; solitude or
loneliness because of a lack of social support from society in general; socio-
economic problems including lack of financial resources; and low income
(Verhofstadt et al., 2017), raising questions about whether socio-economic
supports might alleviate suffering in some cases.
In 2017, within the psychiatric disorders (excluding dementia) category, the

highest number of psychiatric EAS cases reported to the CFCEE involved
people 60 to 69 years old (n=6), 40 to 49 years old (n=5), and 50 to 59 years old
(n=5) (CFCEE, 2018a). From 2014 to 2017, the highest number of psychiatric
EAS cases (excluding dementia) reported to the CFCEE involved people 50
to 59 years old (n=36), out of a total of 141 reported cases during that period
(CFCEE, 2018a).
In 2017, the highest number of psychiatric EAS cases for dementia reported
to the CFCEE involved people aged 80 to 89 years old (n=8) (CFCEE, 2018a).
From 2014 to 2017, the largest number of psychiatric EAS cases reported to
the CFCEE for dementia involved people aged 80 to 89 years old (n=29), out
of a total of 60 reported cases during that period (CFCEE, 2018a).
5 . 6 E VA LUATI O N OF PAT I E NT S R E QU E S T ING

P S YC HI ATR IC E AS

In 2017, there were 83 psychiatric EAS cases (excluding dementia) in the
Netherlands (RTE, 2018a). The physician granting EAS was a psychiatrist in
43% of these cases (n=36), a general practitioner in 27% (n=22), a geriatric
specialist in 7.2% (n=6), and another type of doctor (e.g., a doctor training to
be a psychiatrist) in 23% (n=19). The breakdown of reporting physicians was
not provided for dementia EAS cases (RTE, 2018a).
Unbearable Suffering
This criterion is recognized in the Dutch literature as being difficult to define
and apply (Dees et al., 2009; Pasman et al., 2009; van Tol et al., 2010) and is
“the most debated requirement for due care” (Onwuteaka-Philipsen et al.,
2007 as cited in Pasman et al., 2009). Consistent with the priority placed on a
patient’s subjective interpretation of what constitutes unbearable suffering, as
noted above, there is a wide range of descriptions of suffering. Some patients
had chronic, severe, difficult-to-treat depression and had undergone repeated
ECT treatments; two patients had received deep brain stimulation (a surgical
intervention) (Kim et al., 2016). Two-thirds of patients had psychiatric histories
of more than 10 years (Kim et al., 2016). Others, such as the woman with
prolonged grief disorder (Section 5.5.1), received EAS for a disorder lasting
12 months (see below).
A recent study of nine EAS cases from 2012 to 2016 involving people with
intellectual disabilities or autism spectrum disorder points to the challenges
in applying the Dutch suffering criterion using a medical model of disability.
“Difficulties arise when the suffering, or the fact that the suffering cannot be
relieved, is related to the nature of autism spectrum disorder or intellectual
disability itself — as was the case for those who were highly dependent, had
difficulties with social functioning, difficulties in coping with social circumstances,
or a tendency not to cooperate with treatments” (Tuffrey-Wijne et al., 2018).
In a 2016 survey of Dutch psychiatrists, respondents considered the lack of

hopelessness or unbearable suffering an important reason to refuse the request
in 25% of the 66 refused psychiatric EAS requests (Onwuteaka-Philipsen et al.,
2017). Of all Dutch psychiatrists surveyed (n=207), 70% disagreed (18% were
neutral, 12% agreed) with the statement “it is impossible to assess whether
a psychiatric patient’s suffering is unbearable and hopeless”22 (Onwuteaka-
Philipsen et al., 2017).
No Prospect of Improvement and No Reasonable Alternative

The Dutch EAS law requires that the patient’s unbearable suffering must also
have no prospect of improvement and that there is no reasonable alternative
to EAS, as determined by the patient and the doctor together (Gov. of the
Netherlands, 2002). In cases of psychiatric EAS, Kim et al. (2016) reported that
most patients had extensive treatment histories with long-standing disorders,
and 56% (37 of 66) had refused at least some treatment. The most common
reasons were lack of motivation (n=18), concern about harmful side effects
(n=12), and doubt about efficacy (n=10). Twenty percent (n=13) of patients
did not have a history of inpatient treatment. Depressive disorders were the
primary condition in 55% of cases (36 of 66), 39% (26 of 66) had received
ECT (the primary treatment for severe, refractory depression), and 11% (7 of
66) had tried an MAO inhibitor (an established drug for treatment-resistant
depression, as mentioned in the NVVP guidelines) (Kim et al., 2016). Based on
data from the 1996 national Dutch study, Groenewoud et al. (1997) found that,
among those making a request for psychiatric EAS, 64% (129 of 202) had refused
remaining treatment options (medication, psychotherapy, electroconvulsive
therapy, and inpatient or day-treatment).
There is one example in the Netherlands of someone accessing psychiatric

EAS for prolonged grief (RTE, 2012). A woman between 70 and 80 years old
received psychiatric EAS for prolonged grief 12 months after the death of
her husband (RTE, 2012). Some Working Group members feel that having
a request for EAS accepted on the basis of this disorder after 12 months of
symptoms was surprising because the disorder itself is not well understood.
Other Working Group members disagree that it was surprising. The DSM-5
lists Persistent Complex Bereavement-Related Disorder under “Conditions for
Further Study;” it requires 12 months of symptoms for the diagnosis in adults
(APA, 2015), and may not be well understood (Prigerson & Maciejewski, 2017;
Reynolds et al., 2017). The RTE deemed this case to meet the “no reasonable
alternative” criterion, after consultation with a SCEN doctor and another
independent psychiatrist:
The patient was experiencing serious psychological suffering in reaction

to what was an irremediable and disastrous situation for her, accompanied
by symptoms of reactive depression that stemmed from a complex
prolonged grieving process. It is the opinion of the committee that her
suffering is of a medical nature. The patient had tried both medication
and intensive counselling as part of the bereavement process. Neither
type of treatment had any effect at all. Given this fact, the reporting
doctor and the independent doctors consulted concluded that there was
just a small chance that the life situation of the patient would improve
enough for her to find life bearable. As such, the committee is of the
view that the unbearable suffering of the patient without any prospect
of improvement is supported by sufficient reasoning.23
(RTE, 2012)
The RTE’s judgment accepted the following interpretation of futility used

by one of the consultants: “[I]t is never possible to be certain if pathological
grief will disappear when time passes, but due to the intensity of the grief a
year after the loved one died, the limited social network, and the persisting
wish of the patient to no longer live without her husband, recovery seemed
less likely” (RTE, 2012).24 Some Working Group members believe that such
an interpretation of futility sets a low bar on what qualifies as futile to treat,
while other Working Group members disagree.
The study by Kim et al. (2016) also found that physicians disagreed about the
results of evaluating patients for various eligibility criteria in 24% of cases (16
of 66); 81% of disagreements (13 of 16) were about judgments of the futility
of treatment. In the 1996 national study, 11% (7 of 62) of psychiatric EAS
cases involved people whose psychiatric consultants had determined they had
a treatable psychiatric disorder (Groenewoud et al., 1997). The 1996 study also
found that, among 202 psychiatric EAS requests, psychiatrists reported that
63% of people (128 of 202) were still living: 35% (70 of 202) no longer wished
to die, 18% (37 of 202) still persistently asked for EAS, and 10% (21 of 202)
still asked for EAS but less persistently. In 2% of the requests (4 of 202), EAS
was performed by the responding psychiatrist, another physician performed
EAS in 3% of cases (6 of 202), 5% (10 of 202) died from natural causes, and
16% (32 of 202) died by suicide (Groenewoud et al., 1997).
In the 2016 survey of Dutch psychiatrists, respondents indicated that the

availability of alternative treatment(s) was an important reason to refuse
the request in 53% of the 66 refused psychiatric EAS requests (Onwuteaka-
Philipsen et al., 2017). Of all Dutch psychiatrists surveyed (n=207), 56% agreed
(22% were neutral, 22% disagreed) with the statement “that a psychiatrist,
when deciding whether or not to grant a request, need not take account of
the solely theoretical possibility that an effective therapeutic treatment might
become available in future” (Onwuteaka-Philipsen et al., 2017).25
Capacity Assessment
The NVVP states that:
[I]n principle, each [due care] requirement must be met. However,

the committee sees scope for allowing a small margin in specific cases.
This will require the interrelationship of each of the requirements to
be examined. This applies primarily to the criterion of the unbearable
nature of the suffering, the most subjective criterion and the one that is
most difficult to establish objectively. A situation is possible where one
of the requirements will not have been met in full, but the patient’s
suffering is so evidently unbearable that the healthcare practitioner
is nevertheless able to rely on duress in the sense that he or she was
acting out of necessity.
For instance, a psychiatrist may feel that the situation he or she is

dealing with is one of particularly urgent necessity if the patient is in
an unbearable, inhumane situation with no prospect of improvement
(for example, in the case of very lengthy use of segregation or forced
feeding) and clearly and repeatedly requests assistance with suicide. If
the request is convincing, understandable and palpable, a departure
from the guidelines could be regarded as unjustified on the basis of
a strict standard of decisional competence, for example, because the
patient may also be harbouring psychotic motives. In the committee’s
view, there should be scope for assisted suicide in such cases.26
(Berghmans et al., 2009)
Therefore, according to the NVVP, there may be situations where people

do not meet a high standard of decisional competence, yet still should be
permitted to received EAS (Berghmans et al., 2009). Doernberg et al. (2016)
argue that the normative stance, the lack of a high level of scrutiny, and
the relatively low threshold used by physicians are areas of concern for the
practice of psychiatric EAS in the Netherlands. This could be particularly
problematic, as some psychiatric disorders associated with psychiatric EAS
requests — including schizophrenia, cognitive impairment, eating disorders,
and severe depression — raise the risk of incapacity (Section 4.1.1).
According to the RTEs’ definition, “decisional competence means that the

patient is able to understand relevant information about his situation and
prognosis, consider any alternatives and assess the implications of his decision”
(RTE, 2015b). This definition, which refers to the patient’s ability to understand
and appreciate relevant information, is quite similar in content to Canadian
criteria for capacity discussed in Section 4.1.1. In Belgium, the person must be
competent and conscious at the time of making the request (Gov. of Belgium,
2002).
Doernberg et al. (2016) argue that their study of 66 Dutch psychiatric EAS case
report summaries from 2011 to 2014 shows that, even in complex psychiatric
cases, the physicians involved (and the RTE reviewing them) did not seem to use
a high level of scrutiny nor require a high threshold for capacity. In 55% (36 of
66) of cases, the reports contained assertions about judgments relating to global
capacity (e.g., “the patient was mentally competent”), without any reference
to specific capacity criteria (such as the ability to understand, appreciate,
or reason), even in, for example, patients with schizophrenia who may have
prominent psychotic symptoms, or patients with psychotic depression. In such
complicated cases of people at risk for incapacity, the authors note, “more
explicit discussion of how such patients were able to meet the various capacity-
specific criteria, despite their symptoms, would be expected” (Doernberg et al.,
2016). In 32% (21 of 66) of cases, the physicians provided further evidence
regarding capacity-specific abilities, such as “perfectly able to indicate what
were the pros and cons to her of the alternatives offered, thus it was assessed
that she was able to weigh information” (Doernberg et al., 2016). In the view of
Doernberg et al. (2016), some of these explanations indicate a low threshold
was used. For example, a physician said “in general” the patient was competent
despite noting their ability to “use information in a rational way was doubtful”
(Doernberg et al., 2016). Overall, considerable weight was placed on a patient’s
ability to communicate a stable choice, which was present in all 66 cases. In 12%
(8 of 66) of cases, the primary physician and consulting physician disagreed
about a patient’s capacity to consent to EAS, and the RTE generally accepted
without comment the judgment of the primary EAS performing physician,
even in cases where the physicians chose to follow generalists’ opinions over
specialists’ opinions (Doernberg et al., 2016).
It should be noted that this study was based on RTEs’ summaries of the reports
submitted by the physician, as well as on the RTEs’ follow-up communications
with physicians (written feedback or face-to-face interviews in some cases). There
is a question whether high-threshold evaluations were generally performed,
but details were not included in the RTE case reports. Doernberg et al. (2016)
argues that this is unlikely, given that, in a third of the cases (often where
people did not have major risk factors for incapacity), the reports include
physicians’ criteria-based reasoning; further, it is assumed that the RTE would
not omit supporting evidence in more complex cases as the reports can be
quite detailed. There were also cases in which physicians explicitly said that
a person’s ability (e.g., to use information in a rational way) was lacking but
still found the person competent — with the RTE accepting this reasoning
(Doernberg et al., 2016).
In contrast, Rooney et al. (2017) state that “[RTE case reports] are summary
documents meant to encourage discussion, not grounds for accurate
generalizations about medical practice,” and note that they are plain-language
reports that might not contain technical details.
A recent detailed analysis of nine cases of EAS from 2012 to 2016 involving
people with intellectual disabilities or autism spectrum disorder echoed the
findings of Doernberg et al. (2016): “In the reported case summaries, it appears
that the bar [for capacity] is not set high” (Tuffrey-Wijne et al., 2018).
In a 2016 survey of Dutch psychiatrists, respondents who had previously granted

and/or refused psychiatric EAS requests (66 of 207 respondents) answered
detailed questions about the last time they had refused a request for psychiatric
EAS (Onwuteaka-Philipsen et al., 2017). Eight respondents (12%) indicated
that the main reason they declined the request for EAS was that it was not
voluntary and well-considered. All of the psychiatrists who were sent the survey
were asked about the NVVP guidelines concerning requests for psychiatric
EAS from people with reduced “decisional competence” (Berghmans et al.,
2009) (see above quote at the start of this section). Of the 207 psychiatrists
who completed the survey, 82% disagreed with the statement: “[i]n the case of
chronic psychiatric patients less demanding requirements need to be set for
the decisional competence requirement,”27 and 18% agreed a lower threshold
may be acceptable in some cases (Onwuteaka-Philipsen et al., 2017). Some
Working Group members observe that the majority of Dutch psychiatrists
(63%) would not perform psychiatric EAS (Onwuteaka-Philipsen et al., 2017)
and hypothesize that these psychiatrists may be unlikely to support the use of
a low degree of scrutiny or a low threshold for capacity assessments in the EAS
context. In addition, these Working Group members believe that psychiatrists
who do not agree with the need for high scrutiny or a high threshold for capacity
may be more likely to be involved in psychiatric EAS. Other Working Group
members believe that, while this survey sheds light on the attitudes of Dutch
psychiatrists, it does not provide any evidence that a high level of scrutiny or
high threshold for capacity are not used in practice.
Consultations
Dutch law does not require unanimity among consultants prior to providing
EAS (approval does not require more than one consultant), and in general,
the decision on whether to proceed lies with the responsible physician (i.e., the
physician performing EAS). While consultation with other physicians was
widespread, one in nine cases had no independent psychiatric input (7 of 66),
contrary to NVVP guidelines or the general recommendation of the RTE. In
18 cases (27%), the physician performing EAS was new to the patient, and
in 14 of these 18 cases, physicians were from the End-of-Life Clinic (Box 5.1).
Disagreement among physicians about patient eligibility occurred in 24% (16
of 66) of cases (Kim et al., 2016). Cases of psychiatric EAS in which psychiatric
consultants “explicitly had advised against” EAS were reported as early as the
1996 national study (Groenewoud et al., 2004). That study also noted that 19%
(13 cases) of psychiatric EAS were carried out “despite the consultant’s judgment
that transference (i.e., patient’s redirected emotions from a past figure onto the
physician) and countertransference (i.e., the physician’s emotional reaction to
the patient) had influenced the decision-making.” In a paper focused on nine
EAS cases involving people with intellectual disabilities and/or autism spectrum
disorder, Tuffrey-Wijne et al. (2018) note that the involvement of specialists
(i.e., with expertise in intellectual disabilities) in the evaluation of such cases
is rare (it occurred in one of nine cases).
Rate of Psychiatric EAS Approval in the Netherlands

A 1996 survey of psychiatrists (as part of an early national study) showed that
about 10% (20 cases) of psychiatric EAS requests were approved (Groenewoud
et al., 2004), 35% of people (70 cases) no longer wished to end their lives, 16%
of people (32 cases) ended their lives without assistance from a physician, and
5% of people (10 cases) died of natural causes. The remainder still requested
EAS, but the exact effective approval rate was not clear (Groenewoud et al.,
1997). The every-five-year Dutch national study used data collected through
physician surveys on refused requests. Therefore, data is available about the
number of physicians refusing requests, and why (i.e., whether they felt the cases
met the due care criteria); however, the total number of refused requests is
not known (Onwuteaka-Philipsen et al., 2017).
Snijdewind et al. (2015) reviewed the End-of-Life Clinic’s first year of operation
and found that, based on registration materials (provided by patients and their
families), 121 requests were received from those with psychiatric conditions. Of
those 121 psychiatric EAS requests, 5.0% were granted (6 of 121), 74% were
rejected (89 of 122), the patient died before a decision was reached in 7.4%
cases (9 of 121), and the request was withdrawn in 14% of cases (17 of 122).
The most recent national study, The Third Review of the Dutch Act, asked
207 psychiatrists about their experiences with psychiatric EAS (Onwuteaka-
Philipsen et al., 2017). Dutch psychiatrists received approximately 1,100 requests
for EAS from psychiatric patients in 2016, of which an estimated 60 (5%) were
granted (Onwuteaka-Philipsen et al., 2017). In the same survey, 10 psychiatrists
answered questions about the last time they granted an express request for
EAS from a patient with a psychiatric disorder. The patients who had their
requests refused were more often female, were younger on average (59.5 years),
were more likely to have a personality disorder, and were less likely to have
a secondary physical disorder. When psychiatrists were asked to compare the
differences between the express requests they had accepted and past requests
they had refused, they found that fewer of the refused patients were assessed
as having decisional competence, and that a lower percentage of those with
refused requests were regarded as being capable of making a voluntary and
well-considered request. Treatment options were also deemed available in
the case of refused requests, whereas this was not so for granted requests
(Onwuteaka-Philipsen et al., 2017).
5.6.2 Belgium
Unbearable Suffering
Thienpont et al. (2015) state that “the concept of ‘unbearable suffering’ has
not yet been defined adequately, and that views on this concept are in a state
of flux.” Nevertheless, they describe the 100 consecutive people requesting
psychiatric EAS as follows: “in all patients, the suffering was chronic, constant
and unbearable, without prospect of improvement, due to treatment resistance”
(Thienpont et al., 2015). A related study qualitatively analyzed the testimonies
of 26 of these patients and described their suffering (Verhofstadt et al., 2017);
some of the findings are discussed in Sections 4.1.2 and 5.5.2.
No Prospect of Improvement and Futility

As noted above, all 100 patients in the Thienpont et al. (2015) were deemed to
be suffering “without prospect of improvement, due to treatment resistance.”
Further testing and/or treatment to confirm diagnoses or to ensure that
conditions were not remediable was required for 38 patients (Thienpont et
al., 2015).
Of the 100 psychiatric EAS requests reported by Thienpont et al. (2015), 48 were
accepted for EAS, and EAS was performed for 35 individuals; 11 cancelled or
postponed the procedure (the authors explain that for 8 of these 11 patients
“simply having this option gave them enough peace of mind to continue living,”
2 withdrew requests because of strong family resistance, and 1 person could
not have EAS because they were incarcerated); and 2 died by suicide prior to
the procedure. Of the patients whose requests were not accepted (n=52), 38
withdrew their requests before receiving a decision, 8 “continued to pursue”
their requests, 4 died by suicide, and 2 died from other causes. Thus, 43 people
died, 8 were still pursuing a request for psychiatric EAS, and of the remaining
49, 38 withdrew requests before a decision was reached and 11 cancelled or
postponed the procedure after their request was accepted (Thienpont et al.,
2015).
Between one and four years after their initial evaluation, 43 patients had died,
either by EAS (n=35, as noted above), suicide (n=6), palliative sedation (n=1),
or anorexia nervosa (n=1) (Thienpont et al., 2015). Of the 57 people who were
alive one to four years later, 9 requests “were still in process and no decision
had been reached,” and 48 requests were on hold because the patients were
“managing with regular, occasional or no therapy” (Thienpont et al., 2015).
Capacity
In the (Thienpont et al., 2015) study, all 100 people in the consecutively
requested psychiatric EAS were deemed competent. A number of diagnoses
were associated with an increased risk of incapacity, but no information is given
as to how their status was determined.
Consultations
Consulting a specialist (psychiatrist in cases of psychiatric disorders) is a legal
requirement only in Belgium for cases where death is not foreseeable (Gov.
of Belgium, 2002; RTE, 2016). However, this consultation does not always
occur. Dierickx et al. (2017) found that, in cases where the patient did not
have a foreseeable death, the third physician involved was a psychiatrist in all
cases of mood disorder accompanied by an additional psychiatric disorder, in
all cases of “other psychiatric disorders,” and in 87% of mood disorder cases
(i.e., with no additional psychiatric disorder diagnoses). For comparison, the
second physician involved was usually a general practitioner in cases of mood
disorders (69%) and other psychiatric disorders (59%) (Dierickx et al., 2017).
In 2017 in Belgium, there were 26 psychiatric EAS cases (excluding dementia),

and in 96% of these cases (n=25), the second doctor consulted was a psychiatrist
(CFCEE, 2018a). In 17% of these cases (n=4), the psychiatrist had also received
additional training related to end-of-life decision-making. There were also 14

psychiatric EAS cases involving people with diagnoses of dementia, and in 43%
of these cases (n=6) the second doctor consulted was a psychiatrist (CFCEE,
2018a).
Rate of Psychiatric EAS Approval in Belgium

While the psychiatric EAS acceptance rate is not known, the rate of granted
requests for all EAS in Belgium increased from 55% in 2007 to 77% in 2013, with
100% of EAS requests granted for some groups of patients, such as those with
nervous system disorders (Dierickx et al., 2015). An estimate of the psychiatric
EAS acceptance rate in Belgium from 2007 to 2011 is provided by Thienpont
et al. (2015). Excluding those who changed their minds (and those who died)
prior to completion of their evaluation, the acceptance rate is 48 of 56, or 86%.
However, if those who changed their minds and withdrew requests, and those
who died, are included in the acceptance rate calculation, approximately half
of those seeking psychiatric EAS were not approved (a 48% acceptance rate)
(Thienpont et al., 2015). It is difficult to statistically evaluate what predicts the
approval of a psychiatric EAS request, because the Flemish studies do not use a
category specific to psychiatric EAS requests. Instead, such requests fall within
the “other diseases” category, making direct estimates of granted psychiatric
EAS requests difficult to enumerate.
5 .7 HO W P S Y C H I AT RI C E AS I S M ONITOR ED
I N TH E NE T H E RL ANDS AND B ELGIU M
Both the Netherlands and Belgium monitor EAS through a retrospective review
of physician self-reports, in order to determine whether physicians are following
the legal due care criteria (i.e., eligibility criteria and procedural safeguards)
(CFCEE, 2016b; RTE, 2016; Rooney et al., 2017). It is estimated that 20% of
all EAS cases are not reported to the RTEs in the Netherlands (Rietjens et al.,
2009; Onwuteaka-Philipsen et al., 2017), and in Flanders, Belgium an estimated
47% of EAS cases were not reported to the CFCEE in 2007 (Smets et al., 2010).
Non-reported cases often involved patients 80 years or older, with a primary
diagnosis of cancer (i.e., not psychiatric), and physicians noted that the degree
of life shortening was limited to a week or less (Onwuteaka-Philipsen et al.,
2017). Others have noted that these physicians did not consider the deaths to
be EAS (Rietjens et al., 2009). The primary feature of these unreported cases is
that doctors tended to use morphine rather than drugs designated for EAS. In
all of these cases, physicians reported that they intentionally hastened deaths
at the request of the patients (Onwuteaka-Philipsen et al., 2017).
Of over 62,000 combined cases of EAS between 2002 and 2016, due care was
judged to have not been met in 89 cases in the Netherlands and 1 case in Belgium
(Mason & Weitenberg, 2015; Miller & Kim, 2017). A recent study examined the
32 of the 33 cases in the Netherlands where the RTEs judged “due care not met”
(DCNM) between 2012 and 2016 (Miller & Kim, 2017). Most DCNM cases were
due to violations of procedural criteria (e.g., use of incorrect medications, lack
of independence of consultants), mostly in the context of terminal cancer. In
ten cases, the RTEs found violations in the application of the eligibility criteria.
Eight of these ten cases involved either neurological or psychiatric disorders
or both. In seven of the ten cases, the violation involved the “no reasonable
alternative” criterion. Five of the ten cases were performed by physicians from
the End-of-Life Clinic (during which time the Clinic was involved in 5% of all
Dutch EAS cases). In addition, some physicians performed EAS when they
“realised that it was a very difficult case and that the limits of the law would be
sought here” (Miller & Kim, 2017).
The role of consultants specially trained in EAS law (SCEN doctors) in DCNM
cases has been reviewed in the literature. The RTEs have found that, in the DCNM
cases described above, these consultants often either agreed with the primary
physician or they played an active role in facilitating EAS. This more active
role can include: taking over key aspects of the case; advising referral to the
End-of-Life Clinic where the clinic physician then engaged this consultant as
an “independent consultant” for the case; and advising a consulting physician
not to seek further specialist consultation (where not seeking consultation was
the focus of the RTE’s DCNM judgment) (Miller & Kim, 2017).
5.7.1 Monitoring of Psychiatric EAS

As of 2016, there were a combined few hundred cases of psychiatric EAS in the
Netherlands and Belgium. Each country has had one DCNM psychiatric EAS
case. In the Dutch case, a woman in her 80s with chronic depression wanted
assistance from the End-of-Life Clinic (Case 2014-01) (RTE, 2015a). The clinic
physician, who was not a psychiatrist, met the patient for the first time just over
three weeks before her death, and did not conduct any one-on-one interviews
with the patient (the patient’s children were present during both interviews).
He did not consult any psychiatrists, was not familiar with the NVVP guidelines,
and stated he “was in no doubt” about the patient’s prognosis. The RTE found
that the notifying physician should have taken more time to talk with the
patient, and an additional expert should have been consulted (RTE, 2015a).
The single DCNM case in Belgium involved a physically healthy 85-year-old

woman who requested EAS for reactive depression after her daughter died.
No detailed official account has been released; the case was documented by
an Australian journalist on video (Mason & Weitenberg, 2015).
The extremely low rate of DCNM cases (0.2% in the Netherlands and 0.008%
in Belgium) may reflect that, for the RTEs, the EAS law’s primary function is:
1. to create legal certainty for doctors caught in conflicting obligations;
2. to provide transparency in the practice of EAS and public scrutiny; and
3. to safeguard, monitor and promote the care with which medical decisions about
termination of life on request are taken and the quality of such decisions by
bringing matters into the open and applying uniform criteria in assessing
every case in which a doctor terminates life.
(RTE, n.d.)
One psychiatric EAS case further illustrates the RTEs’ interpretation of the
EAS law as it relates to creating legal certainty (case 2013-27). This patient
had attempted suicide by jumping off a building, which led to a broken thigh
and hospitalization. The patient refused all medical treatments and requested
EAS. In the words of the RTE, the physician “complied with the patient’s wish
almost at once” (as quoted in Kim et al., 2016). The RTE was “puzzled” by this
haste; it criticized the physician for prematurely opting for the EAS evaluation,
even going so far as to state that the RTE could “not exclude the possibility
that the patient might yet have accepted treatment...” (as quoted in Kim et al.,
2016). The RTE deemed that due care was met for this EAS, reasoning that,
despite their skepticism about the doctor, the case met the due care criteria at
the moment EAS was implemented (Kim et al., 2016).
It should be noted that the role of the RTEs, through annual reports and the
Code of Practice, is not to ensure that physicians follow EAS law, but rather
to determine whether physicians conducted EAS in a thorough, professional
manner (Miller & Kim, 2017).
5 .8 I M P LI CAT I ONS OF T H E I NT E R N ATIONAL DATA
5.8.1 New Safeguard Developments in Belgium and the Netherlands

Recently, several documents related to psychiatric EAS have been published by
prominent organizations in Belgium that argue for supplemental or further
safeguards beyond what is required by the law.
First, in November of 2017, the VVP in Flanders approved an advisory document

(VVP, 2017) that is heavily based on the 2009 Dutch NVVP guidelines (Berghmans
et al., 2009). The document follows the NVVP’s guidelines in assessment of
suffering, capacity and informed consent, transference/countertransference,
and futility. For example, a patient can be deemed untreatable only after all
indicated standard biological, psychotherapeutic, and social interventions
have been tried and tested. The VVP document also states “[e]very patient is
entitled to refuse a treatment offering a reasonable prospect of success, but
this will make it impossible to show that the ‘medically hopeless condition,’
‘untreatable,’ and ‘impossibility of alleviating the suffering’ criteria have been
met, and will thus preclude euthanasia” (VVP, 2017).28
But the 2017 VVP advisory document also emphasizes the following points
(note this list is not exhaustive):
• It advocates a “twin track policy” in which, during the EAS evaluation process,
the person making the request is also required to pursue recovery-oriented
engagement with a different physician, i.e., not just to focus on the wish to
die but also on life.
• At least two psychiatrists must be involved in each case. All three doctors
must ensure that all of the due care criteria are evaluated.
• “There must be two positive recommendations and any negative
recommendations must also be taken into account.”
• The evaluation process must be one where “sufficient time is taken and there
are multiple conversations with the patient” and that this period must be
“far longer” than the statutory minimum of one month.
• Consultation with current and previous key practitioners providing care to
the patient is essential; if the patient refuses to allow the assessing physician
access to the previous practitioner’s views, then the physician “may decide
that he or she will be unable to” perform or evaluate EAS.
• There should be a strong emphasis on the involvement of family and significant
third parties. “The patient’s refusal to have third parties involved may, however,
result in the doctors being unable to perform or evaluate EAS.”
• The final evaluative process and decision-making should involve more than
the patient and the three doctors (the doctor performing EAS and two
consultants), forming a “round table” representing all doctors and healthcare
providers to the patient so they can “discuss it openly and jointly weight up
all the considerations.”
(VVP, 2017)29
Second, an organization representing hospitals and institutions in Belgium,

Zorgnet-Icuro, recently published its ethical opinion on EAS for non-terminal
patients with serious psychiatric disorders (Zorgnet-Icuro, 2018). In it, they
call for legislative changes to the Belgian EAS law, including the following:
• At least one year’s time between the patient’s writing of the EAS request and,
if accepted, their death, rather than one month.
• That the patient discuss their EAS request with designated loved ones (this
is currently optional).
• That an interdisciplinary team of experts examine the EAS request and the
patient’s situation for a longer period of time.
• That the treating physician consult two psychiatrists with expertise in the
patient’s condition. These experts must be independent in relation to
each other, to the patient, and the treatment team. They should examine
the patient’s decision-making ability and the medical hopelessness of their
condition.
• For any EAS request to be granted, the unanimous agreement of both
consulting psychiatrists is required (in the current law, consulting one
psychiatrist is sufficient, and the advice of this psychiatrist is not binding).
• That at least one psychiatrist be part of the CFCEE (nothing is said in the
current law, and there is currently no psychiatrist on the CFCEE).
(Zorgnet-Icuro, 2018)
One major gap in the evidence is that, beyond gender, age, and physical co-
morbidities, there are no associated data on race, ethnicity, socio-economic
status, family involvement, or the social effects of psychiatric EAS. A lack of
patient voices in the discourse surrounding EAS in Belgium and the Netherlands
has also been identified as a knowledge gap (Van Brussel et al., 2014).
There is also no evidence on the effects of psychiatric EAS on families, friends,

physicians, and other healthcare practitioners. Most of the data on effects of
EAS on families and friends are based on terminal patients, and tend to show
there is less grief among the loved ones of patients who chose EAS versus
patients who died through natural causes (Swarte et al., 2003; Kimsma, 2010).
Although there have been cases of psychiatric EAS in the Switzerland and
Germany, little is known about them.
Chapter 6 Potential Implications of Prohibiting or Permitting More MAID MD-SUMC 147
6
Potential Implications of Prohibiting or
Permitting More MAID MD-SUMC
• Potential Implications
• Speculative Implications
• Unique Considerations for Specific Populations
• Potential Safeguards
• Conclusion
6 Potential Implications of Prohibiting or

Permitting More MAID MD-SUMC
Key Findings
Whether to alter the existing law to expand or restrict MAID MD-SUMC eligibility is a
challenging question upon which people disagree. Empirical data and legal arguments
inform specific aspects of the question but whether or not to further permit or prohibit
MAID MD-SUMC also requires ethical judgments by policy-makers.
Evidence can be drawn from Belgium and the Netherlands to inform the discussion
on prohibiting or permitting more MAID MD-SUMC in Canada, while recognizing
the differences that exist among jurisdictions. Despite this evidence, there still exist
important knowledge gaps about potential implications of prohibiting or permitting
more MAID MD-SUMC in Canada, and the effectiveness of possible safeguards.
No other country permits MAID MD-SUMC where one of the eligibility criteria is
based on an individual’s personal assessment of what conditions for relief of their
intolerable suffering they consider acceptable. If Canada were to expand MAID
MD-SUMC using this criterion, it could become the most permissive jurisdiction in
the world with respect to how relief of suffering is evaluated.
If MAID MD-SUMC were expanded, potential safeguards could be adopted to attempt

to ensure that eligibility criteria are observed and evaluation processes are valid and
reliable in distinguishing between those who should and those who should not be
eligible. Ultimately, there is a trade-off inherent in safeguards between taking steps to
prevent MAID MD-SUMC in cases where someone should be ineligible (over-inclusion),
and creating unnecessary delays or impediments where someone should be eligible
(under-inclusion).
If different criteria or evaluation processes are used to assess MAID requests from
people with mental disorders and people with physical disorders, these will need to
be justified based on the unique characteristics of MAID MD-SUMC versus MAID.
Policy-makers in Canada may be faced with the question of restricting or

permiting more MAID MD-SUMC for those not already eligible for MAID.
Various groups have made assertions about the potential impacts of permitting
or prohibiting this practice, from ethical, legal, social, and clinical points of
view. The Working Group studied these claims, and, based on the evidence
(including the CCA’s Call for Input submissions) and their collective expertise,
have identified important potential implications for policy-makers to consider
while engaged in future public debate and decision-making on this issue.
The Working Group brought different perspectives and lenses to bear on the
probability and significance of particular implications, and on how to balance
and respect competing concerns. Since it is the role of policy-makers rather
than the Working Group to make these judgments, this chapter does not
offer recommendations. Rather, it provides, as comprehensively as possible, a
summary of the potential implications of prohibiting or permitting more MAID
MD-SUMC, as well as the evidence underlying these potential implications.
Drawing upon the evidence presented in Chapters 3 to 5, the purpose of

Chapter 6 is to address three key elements of the charge:
• The potential implications for individuals and other affected people, including
their families, care providers, and health practitioners, with respect to
prohibiting or permitting more MAID MD-SUMC.
• The potential impacts on society with respect to prohibiting or permitting
more MAID MD-SUMC.
• The potential safeguards that might be considered should MAID MD-SUMC
be prohibited or expanded in Canada.
6 .1 P O TENT I AL I M P L I CAT I ONS
The Working Group found a range of potential implications that could arise from
changes to the current Canadian MAID law (making it more or less restrictive),
although members disagree on the probability of different implications occurring,
as well as on the significance of different implications. This section considers
the potential implications that could occur were the current legal status of
MAID altered to expand or further restrict MAID MD-SUMC, or if its status
were to remain unchanged. For simplicity, the Working Group uses the terms
prohibiting and permitting more (or permitting more broadly) MAID MD-SUMC.
The term prohibiting generally refers to both the status quo and restricting
MAID MD-SUMC further. The term permitting more refers to expanding MAID
MD-SUMC so that more people whose sole underlying medical condition is a
mental disorder could be eligible for MAID.
Many of the implications discussed relate to concerns about the potential

over-inclusion or under-inclusion of people receiving MAID MD-SUMC.
Over-inclusion refers to people receiving MAID in cases where it should not
occur (due to ineligibility or undue influence), while under-inclusion refers
to capable, eligible people who request the procedure not receiving MAID.
While the Working Group uses the terminology of over- and under-inclusion,
they make no assumption that the law will be changed. It is widely agreed that
there is a need to avoid cases of over-inclusion and under-inclusion if MAID
MD-SUMC were expanded or prohibited, but the conceptual difficulties with
diagnosis and prognosis in the context of mental disorders (Section 3.1) and
the challenges associated with capacity assessment (Section 4.1) suggest that
there may be cases where people disagree about whether a particular person
would be eligible or not. Were MAID MD-SUMC permitted more broadly, the
line determining who would be eligible and who would not be eligible would
be based on ethical and policy choices made by policy-makers, and enacted
by changes to the current MAID legislation. Alternatively, policy-makers may
decide that no changes are needed if the current normative criteria create
their desired division between eligibility and ineligibility. Some Working
Group members note that there is a need for clear, unambiguous criteria in
the legislation, particularly as it applies to people with mental disorders, as was
highlighted by the Canadian Bar Association and the Federation of Medical
Regulatory Authorities of Canada in the CCA’s Call for Input (CBA, 2017;
FMRAC, 2017). Other Working Group members believe that commenting on
the current legislation was not within the scope of this report.
Along with the potential implications, the Working Group identified several
speculative implications for which there was very little or no evidence specifically
related to MAID MD-SUMC. These speculative implications are discussed in
Section 6.2. There is no clear evidentiary line separating potential implications
from those that are speculative, and Working Group members disagree about
how to balance the evidence supporting each implication. The Working Group
notes that there is speculative evidence for all potential implications, as they
all make reference to a hypothetical future.
6.1.1 Current Eligibility Criteria

Current MAID law in Canada does not specifically exclude people whose sole
underlying medical condition is a mental disorder, provided they meet all of
the law’s eligibility criteria. However, in most cases, people will not meet one
or more of the current eligibility criteria; these ineligible cases are the focus
of the following discussion.
As it is beyond the scope of this assessment to evaluate the current legislation,

and as there are many different mechanisms by which MAID MD-SUMC could
be permitted, the Working Group for the most part avoided discussing scenarios
in which one or more of the eligibility criteria were changed in order to further
permit or restrict MAID MD-SUMC. Some Working Group members also felt
that discussions of MAID MD-SUMC in reference to the current law were out
of scope of the assessment.
The current eligibility criteria that are most relevant in the context of MAID
MD-SUMC are:
• Decision-making capacity (s.241.2(1)(b)); and
• A grievous and irremediable medical condition (s.241.2(2)):
-- “incurable illness, disease or disability” (s.241.2(2)(a))
-- “advanced state of irreversible decline in capability” (s.241.2(2)(b))
-- “enduring physical or psychological suffering that is intolerable to
them and that cannot be relieved under conditions that they consider
acceptable” (s.241.2(2)(c))
-- “natural death has become reasonably foreseeable” (s.241.2(2)(d))
(GC, 2016b)
The Working Group identified several important potential implications for

MAID MD-SUMC stemming from challenges associated with applying these
eligibility criteria to people with a mental disorder as their sole underlying
medical condition, which may lead to risks of both over-inclusion and under-
inclusion. For example, in regard to prognosis, some people requesting MAID
MD-SUMC may be assessed as eligible even if their condition would have
improved in the future (potential over-inclusion), and others may be assessed
as ineligible whose condition would never improve (potential under-inclusion).
The impact of these risks is different: in the case of over-inclusion, the risk is that
a potentially full lifespan ends prematurely. Unlike errors of under-inclusion
that may be detected after the fact, it will never be possible to know whether the
person who received MAID might have improved. Thus, over-inclusion cannot
be corrected and, in general, it may be difficult to measure how successful
safeguards are in mitigating this type of risk. In contrast, it may be possible to
detect cases of under-inclusion for specific people (e.g., by noting over time
that the anticipated improvement has not occurred), and to re-assess eligibility
as experience accrues and if prognosis becomes clearer over time. However, if
further treatment or supports prove ineffective or unacceptable, not allowing
an individual to receive MAID MD-SUMC will have caused the prolongation
of intolerable suffering.
Mental disorders are a large and heterogeneous group of conditions, and include
those that can be characterized as having a stable, relapsing and remitting,
progressive, or unpredictable course (Section 3.1). Additionally, most mental
disorders are syndromes (defined by clusters of symptoms and signs), and
different people with the same diagnosis may experience different symptoms.
Prognostication is often difficult, but this is not always the case. For example,
the course of dementia due to Alzheimer’s disease is much clearer than that of
depression (Section 3.1). The Working Group recognizes that such heterogeneity
means the implications of prohibiting or permitting more MAID MD-SUMC
in relation to the eligibility criteria will vary among different types of mental
disorder. Therefore, while the implications discussed below are relevant for
many mental disorders, they are not relevant for all mental disorders.
Capacity
Potential Implication: Were more MAID MD-SUMC permitted, challenges associated
with assessing capacity in people with mental disorders may result in over-inclusion or
under-inclusion.
Under Canadian law, a person with a mental disorder is, by default, presumed
to have capacity to make profound healthcare decisions, including the decision
for MAID (e.g., Gov. of ON, 1996) (Sections 3.6 and 4.1.4). As stated by the
Canadian Psychological Association, “a mental disorder does not ipso facto
indicate that an individual is not competent to make a MAiD decision” (Mikail
et al., 2018). However, as discussed in Section 4.1, the symptoms of mental
disorders can affect decision-making capacity in various ways. A mental disorder
may affect a person’s cognitive faculties, perhaps to the degree where they lack
insight into the presence of the mental disorder and its possible impact on
their thinking. Where a person’s cognitive faculties are sufficiently affected,
they should be regarded as lacking capacity and therefore ineligible should they
request MAID MD-SUMC. This is similarly true for other end-of-life decisions,
including refusing life-sustaining treatment and/or artificial nutrition and
hydration, and consenting to palliative sedation. Mental disorders can also affect
a person’s emotions. Where emotional or affective symptoms are sufficiently
severe, incapacity may arise due to an inability to understand and/or appreciate
the nature and consequences of treatment decisions. As these symptoms relate
to emotions and thinking, it can be clinically challenging to establish with
confidence the point at which people with certain mental disorders lose capacity.
The challenge of assessing capacity for MAID in people with a mental disorder
as their sole underlying medical condition was noted by most stakeholder
organizations in their responses to the CCA’s Call for Input on MAID MD-SUMC,
including medical and legal professional organizations, advocacy groups, and
healthcare facilities. This challenge has been identified by organizations outside
Canada as well. For example, in their statement on physician assisted suicide,
the Royal Australian and New Zealand College of Psychiatrists (RANZCP)
states “ensuring that a person with mental illness has capacity in the [physician
assisted suicide] context may pose significant challenges” (RANZCP, 2016).
These difficulties raise the possibility that, were MAID MD-SUMC more broadly
permitted, some patients might be found capable when they are incapable
(over-inclusion) and some might be found incapable when they are capable
(under-inclusion). As discussed in Section 4.1.1, the reliability of capacity
assessments is unclear, with some studies showing high agreement among
independent psychiatrists assessing decision-making capacity in people with

mental disorders (Kim et al., 2001; Cairns et al., 2005b; Kim et al., 2007; Okai
et al., 2007), and others finding significant rates of disagreement (Marson et
al., 1997; Kim, 2006). Typically, the rate of disagreement is higher for novel
or controversial decisions (Kim, 2006), and MAID MD-SUMC would likely be
seen as a controversial decision. As discussed in Section 5.6.1, a study of 66 case
reports for psychiatric euthanasia or physician-assisted suicide (psychiatric
EAS) in the Netherlands found that the two assessors disagreed on capacity
in 12% (n=8) of cases and agreed in 88% (n=58) of cases (Doernberg et al.,
2016). While the rate of disagreement was relatively low, in most of these cases
psychiatric EAS was carried out without resolving the disagreement (Doernberg
et al., 2016). Under Canada’s current MAID law, two independent assessors
must both agree that a person is eligible for MAID (GC, 2016b).
There are also questions about the appropriate threshold for capacity with
respect to a MAID request, and how it is evaluated. Some Working Group
members think there is a need for a high degree of scrutiny of a patient’s
decision-making abilities, and a high threshold for capacity in cases of MAID
MD-SUMC. As discussed in Section 5.6, some authors argue that, based on their
study of psychiatric EAS eligibility assessments in the Netherlands, clinicians
do not always apply the degree of scrutiny or threshold for capacity that is
appropriate when evaluating requests for psychiatric EAS (Doernberg et al.,
2016). On the other hand, using too high a threshold for capacity could result
in under-inclusion whereby capable people are denied MAID. As discussed in
detail in Section 4.1.4, Working Group members disagree about whether using
different thresholds for capacity for MAID MD-SUMC than for other highly
consequential decisions would be justified on the basis of the characteristics
of MAID MD-SUMC.
Grievous and Irremediable

In order to qualify for MAID in Canada, a person must have a grievous and
irremediable medical condition, as defined by the criteria listed at the start of
this section. The Working Group has identified potential implications related
to each of these criteria. A common theme of these implications (which are
related to all of the criteria except suffering) revolves around certainty. To be
clear, the issue is not whether there are people who have mental disorders
that are irremediable, but rather whether clinicians can confidently determine
whether a particular case is irremediable. According to the Canadian Psychiatric
Association (CPA) “[t]here is no established standard of care in Canada, or
as far as CPA is aware of in the world, for defining the threshold when typical
psychiatric conditions should be considered irremediable” (Standing Senate
Committee on Legal and Constitutional Affairs, 2016). Likewise, the Centre for
Addiction and Mental Health (CAMH) has stated that “[t]here is not enough
evidence available in the mental health field at this time for clinicians to ascertain
whether a particular individual has an irremediable mental illness” (CAMH,
2017). A number of other organizations that responded to the CCA’s Call for
Input shared this view, including the Canadian Mental Health Association, the
Canadian Association for Community Living, and the Ontario Shores Centre for
Mental Health Sciences, among others (CACL, 2017; CMHA, 2017; OSCMHS,
2017). Others have argued that mental disorders can sometimes be considered
irremediable based on studies that demonstrate there are at least some people
who do not respond to treatment (von Fuchs, 2017; Dembo et al., 2018).
Incurable
Potential Implication: Were more MAID MD-SUMC permitted, there could be confusion
around eligibility as it is not clear whether many mental disorders could meet the criterion
of “incurable.”
There are many possible interpretations of the term incurable and whether some
mental disorders can be considered incurable will depend on the definition
chosen (Section 4.1).
Many mental disorders are considered to be chronic conditions, where the focus
is not on a cure, but on the management of symptoms, restoration of function,
and decreasing the risk of complications and relapse (Sections 3.1 and 4.1).
Treatment can often effectively alleviate symptoms, improve quality of life, and
restore a person’s desire to live. With some mental disorders, however, a person
would not be considered cured even if they were displaying no symptoms.
Some people have mental disorders that clinicians deem treatment-resistant,

meaning that a person’s symptoms have not been sufficiently reduced after
having attempted multiple treatments under appropriate conditions. However,
even in these cases, under some definitions, a mental disorder may not be
clinically labelled as incurable. This is not the case for all mental disorders or for
all definitions of incurability, however. CAMH has noted that using a definition
of incurable that defines such a medical condition as not fully abating would
mean that many mental disorders could be considered incurable (CAMH, 2017).
As explained below, CAMH does not support expanding MAID MD-SUMC. In
addition, one may infer from the development of the field of palliative psychiatry
(Berk et al., 2012; Trachsel et al., 2016) that at least some psychiatrists believe
that some mental disorders are incurable (Downie & Dembo, 2016). While
there are exceptions (e.g., dementia as a result of Alzheimer’s disease), the
term incurable is not used by clinicians in the context of most mental disorders.
There are circumstances in which prognosis is more reliable for certain mental
disorders than for certain physical disorders. For example, determining a
prognosis for some neurocognitive disorders is relatively easy, while the future
course of remitting-relapsing forms of multiple sclerosis can be challenging to
predict. On the whole, however, this is not the norm for most mental disorders.
Irreversible Decline
Potential Implication: Were more MAID MD-SUMC permitted, there could be uncertainty
around eligibility, as it is not clear whether most people whose mental disorder is their sole
underlying medical condition could meet the criterion of “advanced state of irreversible
decline in capability.”
Many mental disorders can lead to declines in both mental and physical
capabilities directly through symptoms. Some Working Group members also
believe that indirect factors such as socio-economic hardship, social isolation,
homelessness, addiction, or co-morbid physical conditions can also exacerbate
the symptoms of a person’s mental disorder and thereby contribute to declines
in capabilities (Section 3.3). It is unclear whether these declines would be
considered as an advanced state of irreversible decline in capability, as there is
a lack of clarity about the precise meaning of the irreversible decline criterion,
as well as disagreement about its interpretation in practice. As the Canadian
Medical Protective Association (CMPA) notes:
The CMPA is also aware of the ongoing debate concerning whether the
eligibility criteria in the Criminal Code that the patient be in an “advance
state of irreversible decline in capability” requires an irreversible decline
in physical capability, or whether it should be interpreted broadly so
as to include those suffering only from a decline in mental capability.
While the CMPA interprets the provision based on the information
currently available as requiring an advance state of irreversible decline
in physical capability, clarity is required on this issue.
(CMPA, 2017)
Others have offered a different interpretation:
“Advanced state of irreversible decline in capability” includes declines

in cognitive as well as physical functions; sudden as well as gradual losses
of capability; and ongoing as well as stabilized declines in capability. It is
assessed by the medical or nurse practitioner, and it is assessed relative
to the patient’s prior capability.
(Downie & Chandler, 2018)
This issue is particularly relevant for MAID MD-SUMC, as there may be cases
where people requesting MAID are not experiencing physical declines in
capability. Additionally, the course of many mental disorders is fluctuating,
making it challenging for clinicians to identify whether a decline in capability
is irreversible or temporary (Section 3.1.2). Some organizations, such as the
Canadian Mental Health Association, are of the opinion that the “irreversible
decline” criterion “likely exclude[s] mental illnesses, as they often fluctuate
in symptoms and are remediable with appropriate treatment” (CMHA, 2017).
As discussed broadly for the “grievous and irremediable” criterion, in many

cases the issue is not whether people can be in an advanced state of irreversible
decline because of certain mental disorders, but rather whether clinicians can
confidently determine that the decline is irreversible. These issues will not
be relevant for all MAID MD-SUMC requests as, in some instances, a decline
in capability is predictable, especially when it is the result of certain mental
disorders (e.g., dementia due to Alzheimer’s disease).
International evidence shows that those assessing eligibility for psychiatric EAS
in Belgium and the Netherlands sometimes disagree about whether a psychiatric
illness has no prospect for improvement. As noted in Section 5.6.1, a study
of 66 cases of psychiatric EAS in the Netherlands found that assessors agreed
there was no prospect of improvement in 80% of cases (n=53), and disagreed in
20% (n=13) of cases (Kim et al., 2016). In most cases of disagreement, EAS was
administered without resolving the disagreement (Kim et al., 2016). In Canada,
under the current MAID law, two assessors must both agree that the person is
eligible for MAID (GC, 2016b).
Intolerable Suffering
Canada has a subjective standard for intolerable suffering (“suffering that is
intolerable to [the person] and that cannot be relieved under conditions that
they consider acceptable”) (GC, 2016b), which leaves the determination of
intolerable suffering to the patient. This differs from the laws in the Benelux
countries, wherein the clinician and patient together determine whether there
are no means by which suffering can be relieved (see Section 5.6 for the full
list of requirements).
Potential Implication: Were more MAID MD-SUMC permitted, it may be difficult to

distinguish between (i) a person’s rational perception of intolerability and irremediability
of suffering, versus (ii) a distorted perception that is driven by feelings of hopelessness.
Mental disorders can and do cause enduring and intolerable psychological and
physical suffering. However, certain mental disorders can impair a person’s
ability to rationally reflect on the intolerability and irremediability of their own
suffering, and these disorders are common in people who request psychiatric
EAS in international jurisdictions. For example, in psychiatric EAS studies, many
requestors had a personality disorder (50 out of 100 requesters in a Belgian
study, and 34 out of 66 requesters in a Dutch study)30 (Thienpont et al., 2015;
Kim et al., 2016). Personality disorders, and other psychiatric disorders such
as severe depression, involve maladaptive “ways of perceiving and interpreting
self, other people, and events” (APA, 2013). Not all cases of MAID MD-SUMC
would involve personality disorders, and not all personality disorders impair
a person’s ability to rationally reflect on their suffering. However, it may be
difficult to determine clinically whether a person who requests MAID MD-SUMC
has a distorted perception of their suffering (as intolerable with no potential
for improvement) resulting from a symptom of their disorder. In some cases, it
may be that the patient’s symptoms and/or suffering could be reduced through
treatment or other changes in their lives (e.g., feeling supported, making new
friends), despite their feelings of hopelessness at the time of their MAID MD-
SUMC request. Some Working Group members believe that, in some cases, it
may be possible to determine that a person has a rational perception of the
intolerability and irremediability of their suffering.
Potential Implication: Permitting more MAID MD-SUMC may reduce suffering by

providing eligible people with that option, if needed.
Having the option for MAID may offer a therapeutic benefit to some people,
including those with mental disorders. International evidence suggests that some
(8 of 48) people who were approved for psychiatric EAS in Belgium withdrew
their requests after approval, later indicating that knowing they had the option
“gave them sufficient peace of mind to continue their lives” (Thienpont et al.,
2015). Working Group members disagree about how to interpret this evidence.
Some members believe it indicates that these patients’ suffering was not in
fact intolerable and irremediable due solely to their mental disorders. Others
believe it indicates that being approved for MAID either reduced these patients’
suffering or altered the tolerability of their suffering.
30 “Fifty-two percent (34 of 66) of patients had personality related problems, sometimes without
a formal diagnosis but indicating significant effect on the EAS evaluation” (Kim et al., 2016).
Evidence from Oregon shows that about one-third of those given a lethal
prescription to administer themselves (physician aid in dying, or PAD) never
take the drug, and some suggest this is because they derive comfort from
having it (OHA, 2007; Lindsay, 2009). This is consistent with two interactions
described by Li and Kain (2018) in which two patients experienced relief after
being found eligible for MAID. However, neither of these studies examined
requests for assisted dying where a mental disorder was the sole underlying
medical condition, and thus the relevancy of this evidence is unclear. While
research related to MAID in general may be relevant for MAID MD-SUMC, some
evidence suggests caution. In Belgium and the Netherlands, data demonstrate
that the characteristics of patients accessing EAS are different from those
accessing psychiatric EAS. For example, while men accessed 51% of all EAS
in the Netherlands in 2017 (RTE, 2018a), women accessed 70% of psychiatric
EAS between 2011 and early 2014 (Kim & Lemmens, 2016).
Natural Death Has Become Reasonably Foreseeable

The majority of people with a mental disorder as their sole underlying medical
condition will not qualify for MAID because they do not meet the “natural death
has become reasonably foreseeable” criterion. As discussed in Section 4.1.2,
there is disagreement over what is meant by the term “reasonably foreseeable,”
and different MAID assessors and providers across Canada use different
interpretations.
Potential Implication: Permitting more MAID MD-SUMC through the removal of the
“reasonably foreseeable” criterion may expand the MAID eligibility to include many
chronic conditions.
While MAID MD-SUMC is permitted in Canada, the majority of people with
mental disorders are excluded because their natural deaths are not considered
“reasonably foreseeable.” This criterion also excludes people with a range of
physical conditions who would otherwise qualify. For example, a person with
severe pain from arthritis could meet the criteria of being capable, having an
incurable illness, being in a state of irreversible decline, and having intolerable
suffering that cannot be alleviated by treatments they find acceptable, but may
be in a position where their death is not considered reasonably foreseeable.
Therefore, were MAID MD-SUMC permitted more broadly through the
elimination of the “reasonably foreseeable” criterion, a range of conditions
in addition to mental disorders could become eligible for MAID. As discussed in
Chapter 5, evidence from the Netherlands and Belgium demonstrates that
people have accessed psychiatric EAS for a range of conditions where death is
not reasonably foreseeable. These conditions include depression, personality

disorders, and anxiety disorders, but also autism (CFCEE, 2016; Kim et al., 2016),
which may fall outside of what some would consider to be a mental disorder.
Potential Implication: Prohibiting MAID MD-SUMC may potentially cause people with
mental disorders to engage in voluntary stopping of eating and drinking (VSED) in
order to become eligible for MAID or as an alternative way to die.
As most people with a mental disorder as their sole underlying medical condition
will not meet the “reasonably foreseeable” criterion for MAID, some Working
Group members think it is important to consider that this lack of access to
MAID may potentially lead some people to engage in VSED in order to hasten
the foreseeability of their death. At present, there is limited evidence related
to VSED and MAID MD-SUMC specifically. Other Working Group members
feel the following discussion of this implication is unsubstantiated based on
the evidence available.
At least two people in Canada have used VSED to qualify for MAID where
they met all but one of the eligibility criteria (Section 2.2.4). One of these,
a 56-year-old woman, had multiple sclerosis and initially failed to meet the
criterion of “natural death has become reasonably foreseeable” (GC, 2016b;
CPSBC, 2018). The other (a 61-year-old man in Quebec) experienced a series
of debilitating strokes that resulted in an inability to walk, losing his ability to
speak, and experiencing a large amount of pain. He initially failed to meet the
criterion of “at the end of life” (a requirement for assisted dying in Quebec)
(Gov. of QC, 2014; McKenna, 2016; Standing Committee on Justice and Human
Rights, 2016b; CPSBC, 2018). However, neither of these people had a mental
disorder as their sole underlying medical condition, and thus the relevancy of
this evidence to MAID MD-SUMC is unclear. Prior to the legalization of MAID
in Canada, a woman with a mental disorder (Huntington’s disease) chose to
publicly end her life through VSED in order to control her death while she
had the capability to do so (Martin, 2014).
In the Benelux countries, people with psychiatric disorders are not excluded
from accessing psychiatric EAS by a “reasonably foreseeable death” criterion.
However, there is evidence that VSED has been used as an alternative way to
die when EAS requests have been refused. In one study from the Netherlands,
7 out of 6,861 deaths resulted from VSED after requests for EAS were refused
(Onwuteaka-Philipsen et al., 2012). It is not known whether any of these people
had a mental disorder.
6.1.2 Vulnerability and Autonomy

Vulnerable groups and individuals are susceptible to harm. As noted in Chapter 3
and Section 4.3, some people with mental disorders are considered vulnerable,
insofar as having a mental disorder is associated with socio-economic hardship,
discrimination, and disability. As a result, some people with mental disorders
may be less independent and have a reduced ability to defend or promote
their own interests (whether those interests are to avoid or to access MAID).
The difficulty of addressing vulnerability is that restricting some people’s
choices in order to protect them may simultaneously deny their (and others’)
autonomy. Concerns related to the vulnerability of those who would request
MAID MD-SUMC centre on voluntariness and ensuring that MAID requests are
autonomous and not a result of pressure from other people or society, and
that MAID requests are not denied as a result of paternalistic attitudes about
people with mental disorders.
Vulnerability
Potential Implication: Prohibiting or permitting more MAID MD-SUMC may have an
impact on mental health stigma and the vulnerability of people with mental disorders.
Some Working Group members believe that permitting more MAID MD-SUMC
may reduce mental health stigma by demonstrating that people with mental
disorders have capacity, that their suffering is serious, that mental disorders
are not due to character flaws or circumstances within their control, and that
their right to self-determination should be respected.
Walker-Renshaw and Finley (2016) ask, “Would prohibiting the availability of

physician-assisted death for capable persons suffering intolerably from severe,
treatment refractory mental illness be just another form of stigmatizing mentally
ill persons?” In the past, there has been significant stigmatization of people
with mental disorders in Canada (Chapter 3). This stigma continues today, and
may contribute to people’s suffering and vulnerability. There is some empirical
evidence, based on an Australian survey, that suggests that lower public support
for MAID MD-SUMC, as compared to MAID for physical disorders, is due to
perceptions that people with mental disorders have less autonomy — and at
the same time are more in control of their own condition — than people with
physical disorders (Levin et al., 2018).
Other Working Group members think that permitting more MAID MD-SUMC
may increase mental health stigma because it might bolster the beliefs that
the lives of people with mental disorders are intolerable, not worth living, and
(at least sometimes) hopeless. In Canada, both provincial/territorial Human
Rights Codes and the Canadian Charter of Rights and Freedoms explicitly prohibit
discrimination on the basis of mental disability, including mental disorders (GC,

1982). There is, however, a history of discrimination against people with mental
disorders, including forced institutionalization and sterilization in the name of
eugenics (Section 3.3.3). Some organizations, such as the Council of Canadians
with Disabilities, have argued that permitting MAID MD-SUMC would “increase
the vulnerability of Canadians with psycho-social impairments” (CCD, 2017).
For example, there is the possibility that permitting more MAID MD-SUMC
may result in people with mental disorders seeking it disproportionately as
a way out of chronically difficult circumstances (e.g., poverty, homelessness,
unemployment) that are more likely to affect them compared to the general
population (Section 3.3.2), or due to coercion. In a study of Dutch practice,
social isolation or loneliness was cited as contributing to the suffering of people
who accessed psychiatric EAS in 37 of 66 cases (Kim et al., 2016). In addition,
5 of 66 psychiatrists surveyed about the last time they had refused a request
for psychiatric EAS in the Third Review of the Dutch Act stated that “I had
the impression that the patient was making the request under the pressure
of those close to him or her” (Onwuteaka-Philipsen et al., 2017). Notably, the
same number (5 of 66) stated “I felt pressurised by those close to the patient
to refuse the request” (Onwuteaka-Philipsen et al., 2017).31
Potential Implication: Prohibiting or permitting more MAID MD-SUMC may unjustifiably

discriminate against people with mental disorders.
People with mental disorders have a history of experiencing discrimination
in Canada (Chapter 3). Under the current law, people whose mental disorder
is their sole underlying medical condition are not prohibited from receiving
MAID; however, the majority will not meet all of the existing eligibility criteria.
People with mental disorders have the right to make end-of-life decisions, such
as requesting palliative sedation, refusing artificial nutrition and hydration, and
refusing or requesting the removal of life-sustaining treatment. As discussed
in detail in Section 4.1.4, Working Group members disagree about whether
differential treatment between MAID MD-SUMC and other highly consequential
decisions would be justified because of the characteristics of MAID MD-SUMC.
Some Working Group members believe that prohibiting MAID for people
with mental disorders when it is permitted for people with other conditions
can be seen as discriminatory. These Working Group members note that
historically, broad practices put in place to protect vulnerable groups have
been used to justify the exclusion of people with decision-making capacity from
participating in activities (e.g., biomedical research) when those same people
considered the activity to be of personal or group benefit (Rhodes, 2005).

Other Working Group members believe that differential treatment of people
with mental disorders in relation to MAID is warranted based on the unique
characteristics of mental disorders (such as their impact on people’s capacity,
decision-making, and perceptions of the future); the history of promoting
liberties without providing supporting resources and safeguards leading to
adverse outcomes; and the fact that there are already laws that permit special
protections of people with mental disorders.
Autonomy
Potential Implication: Prohibiting or permitting more MAID MD-SUMC may or may not
respect the autonomy of people with a mental disorder as their sole underlying medical
condition.
Respect for autonomy underlies the legal presumption that adults have decision-
making capacity, and that all capable adults have the right to give or refuse
consent to medical treatment. However, it is also recognized that mental
disorders can impair a person’s ability for autonomous decision-making
(Section 4.3). Furthermore, the concept of autonomy is complex and can be
defined in different ways (Section 4.3). Thus, whether prohibiting or permitting
more MAID MD-SUMC respects or limits the autonomy of people with mental
disorders depends on one’s view of autonomy.
From the individualistic perspective of autonomy, permitting more MAID

MD-SUMC may respect the autonomy of individuals with a mental disorder by
allowing them to independently determine whether (and when and how) their
lives will end. Using this lens, when a person has decision-making capacity, they
have the right to make decisions with respect to their health without external
interference or limitations. Thus, prohibiting MAID MD-SUMC might fail to
respect the autonomy of people with mental disorders who make an informed
and autonomous decision for MAID.
However, permitting more MAID MD-SUMC might also fail to respect the
autonomy of people with mental disorders if there are not sufficient safeguards
to ensure that a patient’s decision for MAID is in fact an autonomous one. A
person may be found to have the legal capacity to make a decision for MAID, but
that decision may not be autonomous if the symptoms of their mental disorder
or a lack of resources is affecting their choice (Chapter 4). For example, a
mental disorder might affect a person’s emotions, distorting their view of their
situation or their ability to reason about the future. Additionally, the severity
or nature of the symptoms of a mental disorder may be affected by a lack of
resources or by other social inequities (e.g., those based on gender or race).
From a perspective of relational autonomy, respecting a patient’s autonomy

requires that the clinician (and possibly others, such as family members) be
involved in the decision-making process, supporting the patient to make a
decision that accords with their preferences and values (Section 4.3.2).
Some Working Group members believe that insofar as mental disorders may
interfere with a patient’s autonomy, and in some cases may specifically predispose
a patient towards wanting to die, prohibiting MAID MD-SUMC might be seen
as respecting and supporting the autonomy of people with mental disorders
by preventing them from making a choice that is not an expression of their
desires, beliefs, values, and preferences. Other Working Group members
believe that if it is acknowledged that all decisions are made under conditions
of constrained choice, labelling the decisions of people who may be classified
as marginalized (socially, culturally or economically) as non-autonomous puts
them at risk of having their decisions disregarded or never invited in the first
place. These other Working Group members argue that if the support required
to satisfy others that a marginalized person’s decisions meet some threshold
of freedom is unlikely to be forthcoming, this paternalism compounds their
lack of freedom (Section 4.3.2).
6.1.3 Mental Healthcare

It is important to consider the implications that prohibiting or permitting more
MAID MD-SUMC may have for mental healthcare in Canada, given the impact
of mental healthcare on the outcomes of those living with mental disorders,
and given that MAID is a service provided by the healthcare system.
Potential Implication: Permitting more MAID MD-SUMC might alter mental healthcare
in Canada, as it may conflict with the professional views and ethics of many mental
healthcare practitioners.
Evidence obtained through CCA’s Call for Input, and the Working Group’s
own expertise, indicate that MAID MD-SUMC is not acceptable to many mental
healthcare practitioners in Canada. CAMH states, “[f]or many mental health
care providers, empowering their patients to access MAID would push that
risk taking beyond the limits of their duty of care and compromise their other
responsibilities to promote life and (to the extent possible) prevent suicide”
(CAMH, 2017). A 2017 survey of 528 psychiatrists in Canada found that 29%
“supported MAID on the basis of mental illness” while 61% opposed it and
10% did not know (Rousseau et al., 2017). A lack of support is also expressed by
psychiatric associations outside Canada. For example, the American Psychiatric
Association (APA) argues that “a psychiatrist should not prescribe or administer
any intervention to a non-terminally ill person for the purpose of causing
death” (APA, 2016). Similarly, the RANZCP states they “[do] not believe that
psychiatric illness should ever be the basis for [physician assisted suicide]”
(RANZCP, 2016).
The limited support for MAID MD-SUMC may stem from healthcare practitioners’
use of recovery-oriented approaches to mental healthcare, as advised by the
Mental Health Strategy for Canada (Section 4.4.1) (MHCC, 2012). In the
recovery-oriented approach to mental healthcare, recovery refers to the ability
to live “a satisfying, hopeful, and contributing life, even when there are on-
going limitations caused by mental health problems and illnesses” (MHCC,
2012); some consider this approach as being in direct conflict with permitting
MAID MD-SUMC (Chochinov, 2016). In the view of some Working Group
members, permitting more MAID MD-SUMC may fundamentally alter the
practice of psychiatry in Canada. Some clinicians disagree, however. The
Ontario Shores Centre for Mental Health Sciences has noted that while “the
majority of mental health professionals believe that the recovery philosophy of
care in mental health is not compatible with the provision of MAID services,”
they argue that “MAID and recovery are not mutually exclusive,” and that
“[d]enying access to the entire mental health population does not align with
recovery principles” (OSCMHS, 2017).
Some Working Group members believe that if the professional views of mental
healthcare practitioners in Canada are in conflict with MAID MD-SUMC,
providing MAID MD-SUMC could be problematic. In Canada, healthcare
practitioners have the right to refuse to participate in MAID or the assessment
of MAID eligibility. If MAID MD-SUMC were more broadly permitted, access
may be limited if health practitioners refuse to participate in assessments of
eligibility or in the delivery of MAID, most notably in regions of the country
where there are already insufficient mental healthcare resources. This may be
particularly relevant if consultation with one or more psychiatrists becomes
mandatory for accessing MAID MD-SUMC, as is the case in Belgium and the
Netherlands for psychiatric EAS (Section 5.2). Other Working Group members
believe that offering MAID MD-SUMC in a setting where mental healthcare is
not available raises important ethical concerns because, if a person is at risk
of seeking MAID MD-SUMC due to insufficient mental health resources, they
will also be at risk of receiving an inadequate MAID eligibility evaluation due
to the same lack of resources.
Potential Implication: Permitting more MAID MD-SUMC may affect the therapeutic
relationship between patients and healthcare practitioners.
Permitting more MAID MD-SUMC may have a negative impact on the therapeutic
relationship between patients and mental healthcare practitioners by making
it easier for healthcare practitioners to give up on challenging patients. This
may in turn encourage some patients to believe there is no hope and that
continuing to live may not be worth the struggle. They might also be more
reluctant to fully engage with mental healthcare practitioners out of fear that
they will be encouraged to seek MAID. One example of this view was provided
by the Ottawa Catholic Physicians’ Guild:
Tampering with the trust needed in the doctor-patient relationship

by inserting the possibility of [MAID MD-SUMC] as an outcome, may
undermine psychiatric treatment; ambivalent patients, knowing that
[MAID MD-SUMC] could be placed on the table as a treatment option,
but not really wanting death, may avoid disclosing their suicidal ideations
to their physician for fear of having MAID foisted upon them.
(OCPG, 2017)
On the other hand, permitting more MAID MD-SUMC may have a positive
impact on therapeutic relationships by encouraging healthcare practitioners
to ensure they propose all possible non-MAID options to relieve suffering.
Permitting more MAID MD-SUMC may also improve the therapeutic relationship
because the patient feels respected, and does not fear being abandoned by
their psychiatrist if they ask about or ultimately choose MAID.
Potential Implication: Were more MAID MD-SUMC permitted, an individual may request
MAID if they are not accessing (or cannot access) psychological interventions, mental
healthcare, or social supports that could relieve their suffering.
There are challenges associated with access to mental healthcare in Canada,
especially for certain sub-populations (Chapter 3 and Section 6.3). Globally,
mental healthcare services are poorly funded compared with other health
sectors, and it is more common for patients to feel unsupported or to be unable
to access such care on a timely and frequent basis (Lancet Global Mental
Health Group, 2007). This is especially true outside Canada’s urban centres;
many rural and remote communities lack equitable access to mental health
treatment (Slaunwhite, 2015; McKenzie et al., 2016).
As a result, there are concerns that, were MAID MD-SUMC permitted, some
people may request it because they cannot access or afford other mental
health treatments that may reduce their suffering. This is a form of reduced
voluntariness (i.e., lack of choice constrains voluntariness of choice). These
concerns have been raised by a number of organizations in the CCA’s Call for
Input — including CAMH, Community Health Nurses of Canada, Covenant
Health, the Ottawa Catholic Physicians’ Guild, and Toujours Vivant – Not Dead
Yet, among others (CAMH, 2017; CH, 2017; CHNC, 2017; OCPG, 2017; TV –
NDY, 2017). Some believe that MAID MD-SUMC could replace treatment for
some people’s mental disorders, especially given the challenge of accessing
appropriate and adequate mental healthcare in Canada. For example, the
sense of isolation brought about by suffering could potentially be mitigated by
a skilled therapist who can provide the patient with a sense of being understood
(Clayton, 2016), but only if such treatment is available.
It is unknown, however, whether those who might seek MAID MD-SUMC are
more or less likely to have access to adequate mental healthcare and social
support. In Belgium and the Netherlands, patients are prevented from accessing
psychiatric EAS if their physician identifies a reasonable alternative treatment
for reducing their suffering (Section 5.2). In the Netherlands, those accessing
psychiatric EAS generally had extensive treatment histories (Kim et al., 2016).
This evidence does not indicate the quality of the mental healthcare received,
although there is no indication that it was anything other than what it normally
is for those not seeking or receiving EAS. Research from Belgium indicates
that some people requesting psychiatric EAS cite socio-economic problems
such as low incomes and financial problems, and environmental factors such
as social isolation, as contributing to their suffering (Verhofstadt et al., 2017).
Evidence on the provision of MAID under the current law (which excludes most
MAID MD-SUMC) indicates that, in general, those with inadequate healthcare
(including palliative care) are not disproportionately seeking MAID. Despite
this, there have been recent concerns raised around access to alternative care
to relieve suffering. In May 2018, the Quebec College of Physicians (CMQ)
sent a letter to Quebec’s Minister of Health and Social Services stating that they
have raised concerns about the availability of palliative care in the province
and that there may have been cases where patients have requested MAID to
die with dignity because alternative care was not available32 (CMQ, 2018). The
32 “Le Collège a lui-même constaté a diverses reprises des difficultés quant à l’accessibilité de
plusieurs patients en fin de vie à des soins palliatifs […] Dans certains cas bien identifiés,
des patients, à défaut de bénéficier de ces soins, pourraient n’avoir eu d’autre choix que de
demander une aide médicale à mourir pour finir leurs jours « dans la dignité », ce qui nous
préoccupe.”
CMQ further explains they have received reports that patients who request
MAID receive priority for resources over others with similar needs33 (CMQ,
2018). In Ontario, a man with a serious neurological disability, Roger Foley,
has launched a lawsuit that includes a challenge of the MAID provisions in the
Criminal Code in response to his being denied self-directed management of
home care (ONSC, 2018). The statement of claim states that the defendants
in the case (his local hospital, health integration network, and others) are
“attempting to force discharge on the plaintiff [from hospital], to work with
contracted [home-care] agencies that have failed him, at the same time offering
to refer him for assisted suicide” (ONSC, 2018). Mr. Foley is claiming that in
lieu of assisted life (adequate home--care services to relieve his suffering) he
has been offered assisted death.
6 .2 S P E CU L AT I V E I M P L I CAT I ONS
The Working Group identified several potential implications for which there was
no evidence or no evidence specifically related to MAID MD-SUMC. As noted,
the Working Group cautions that evidence related to MAID in general may not
be applicable to MAID MD-SUMC because of the likelihood of differences in
characteristics among those seeking MAID more generally and those who would
seek MAID MD-SUMC. Despite this lack of evidence, the Working Group believes
these speculative implications are important to include in order to demonstrate
that these issues were considered, and to identify important knowledge gaps.
Speculative Implication: Impacts on family and friends of people with mental disorders
who receive MAID.
Bereavement may be less acute for the family and friends of those whose receive
MAID, as a result of going through anticipatory grief. Studies have found that
anticipatory grief has resulted in less acute bereavement after cancer patients
accessed EAS in the Netherlands (Swarte et al., 2003). In addition, a study of
family members of patients who received PAD in Oregon found that it “does not
appear to have a negative effect on surviving family members and, in fact, may
help some family members prepare for death” (Ganzini et al., 2009). However,
there are no specific data related to MAID MD-SUMC as there is no international
evidence about the impacts of psychiatric EAS on friends and family.
33 “Il a été signalé au Collège que les patients qui demandaient une aide médicale à mourir
devenaient prioritaires quant aux ressources disponibles (en matière d’évaluation médicale,
psychosociale, d’accompagnement spirituel, etc.) pour les accompagner jusqu’à leurs derniers
moments, au détriment des autres patients en fin de vie ayant des besoins similaires.”
Some Working Group members feel that, compared to suicide, MAID MD-
SUMC may reduce psychological harm to family and friends, who can avoid
the shock of finding the body or of unanticipated death, the guilt over failure
to prevent the death or not having been present to help, and the sorrow over
having been absent.
In contrast, other Working Group members feel that permitting more MAID
MD-SUMC may create psychological harm for family and friends, such as
stress over how to respond to an individual’s desire for MAID, and concern
over whether that request will or should be granted. It may provoke feelings of
anger and/or distrust toward the medical system, which can complicate grief.
Furthermore, because some mental disorders have genetic components and
may be common among relatives of those who seek MAID MD-SUMC, some
Working Group members worry such relatives may be quicker to give up on life
rather than seek (or continue) treatments for their own conditions.
Speculative Implication: MAID MD-SUMC and the overall suicide rate in society.
It is unclear whether permitting more MAID MD-SUMC would increase or
decrease suicide rates, or leave them unchanged. Research has found no
evidence that the legalization of assisted dying affects suicide rates, including
in countries that permit MAID MD-SUMC (Section 4.2.3).
Speculative Implication: Compatibility of MAID MD-SUMC with the current approach

to suicide prevention in Canada.
Some organizations that responded to the CCA’s Call for Input (such as Canadian
Physicians for Life, the Canadian Federation of Catholic Physicians’ Societies,
the Christian Medical and Dental Society of Canada, Physicians’ Alliance Against
Euthanasia, and the Ottawa Catholic Physicians Guild) have argued that MAID
MD-SUMC is incompatible with suicide prevention efforts (CPL et al., 2017;
OCPG, 2017; PAAE, 2017). Some Working Group members agree. One of the
key messages of WHO’s 2014 report Preventing Suicide is “health-care services
need to incorporate suicide prevention as a core component” (WHO, 2014a).
If MAID MD-SUMC were more broadly permitted, it would be treated as a
healthcare service. Therefore, the healthcare system may find itself trying to
prevent suicide for some people with mental disorders, and at the same time
providing MAID MD-SUMC to others.
Other Working Group members believe that there is no clear evidence that
permitting more MAID MD-SUMC would be incompatible with suicide prevention
initiatives.
Speculative Implication: Distinguishing suicidal people from those desiring MAID MD-
SUMC autonomously.
Having a mental disorder is an important risk factor for suicide; a review of
suicide studies found that up to 90% of all people who die by suicide may
have had a diagnosable psychiatric disorder, as determined by retrospective
psychological autopsy (Cavanaugh et al., 2003; Arsenault-Lapierre et al., 2004).
The symptoms of some mental disorders may result in distorted thinking that
influences a person’s desire to end their life. For example, personality disorders
involve maladaptive changes to cognition, such that one’s perception of self is
altered (APA, 2013). It may therefore be difficult for a clinician to determine
whether someone with a personality disorder who requests MAID MD-SUMC
has a rational or distorted view of the hopelessness of their condition.
Some Working Group members argue there is little evidence on how suicidal
people can be reliably and validly distinguished from those who have an
autonomous desire for MAID MD-SUMC and whose sole underlying medical
condition is a mental disorder, regardless of the criteria in place. Other Working
Group members believe that it is possible to distinguish between these two
groups once eligibility criteria are established, but whether such criteria would
offer an adequate threshold for MAID MD-SUMC is an ethical question.
Speculative Implication: Relationship between MAID MD-SUMC, individuals, and suicide.

Among people with enduring, intolerable, and irremediable suffering due
to a mental disorder who would otherwise die by suicide, it is not clear how
many would be eligible for MAID MD-SUMC, or how many would pursue
that option were it more broadly available. Wait times may have an impact
on whether suicides are prevented. Boer (2017) argues that permitting more
MAID MD-SUMC is not likely to prevent suicide, especially not impulsive
suicide, as the wait time to receive psychiatric EAS in the Netherlands can be
quite long (7 out of 10 people included in the study had to wait at least one
year to receive EAS after their first request). Thienpont (2015) found that 2
out of 35 people whose psychiatric EAS request was approved died by suicide
before the procedure could be provided.
If MAID MD-SUMC continues to be prohibited for most people with mental

disorders, some Working Group members believe it is possible that some people
with a mental disorder who want to end their lives will resort to attempting
suicide instead. The College of Registered Psychiatric Nurses of Manitoba has
argued that “[i]f individuals with a primary diagnosis of a mental illness are not
provided with the same freedom and liberties to be eligible for Medical Assistance
in Dying, [...] some may see suicide as their only option” (CRPNM, 2017). As
discussed in Section 5.6, evidence from Belgium shows that approximately
8% (4 of 52) of those whose requests for psychiatric EAS were not accepted
died by suicide (Thienpont et al., 2015). In Canada, the death of Adam Maier
Clayton garnered significant media attention (e.g., Martin, 2017; Picard,
2017). According to media reports, Mr. Clayton was deemed ineligible for
MAID because his death was not reasonably foreseeable. Mr. Clayton had
several mental disorders including depression, anxiety, obsessive-compulsive
disorder, and somatic symptom disorder. Mr. Clayton was a vocal advocate
for extending MAID eligibility to people with a mental disorder as their sole
underlying medical condition. In April 2017, he died by suicide (Martin, 2017;
Picard, 2017). Another death reported in the media was that of 90-year-old
Donna Mae Hill, who attempted suicide three times in the last five years of
her life, including once after being told it would be unlikely she would qualify
for MAID in Ontario (Hill, 2018). While Ms. Hill — who died by an assisted
suicide in Switzerland in May 2018 — had bipolar disorder and lived with “low
grade depression,” she had not had a psychiatric collapse since 1981 according
to her son, and the symptoms of her mental disorder were not the motivating
factor for her desire to access MAID (Hill, 2018).
Other Working Group members believe that if MAID MD-SUMC were more
broadly permitted, there may be cases in which someone may die by MAID
MD-SUMC but who might have otherwise been glad it was not available to
them. Mark Henick, who has depression, an anxiety disorder, and a history of
trauma, has explained that he is happy to be alive despite previously having
felt that death was the only option to relieve his intolerable suffering (CTV
News, 2016; Henick, 2016). Mr. Henick is now a mental health advocate who
believes MAID should not be available to those who request it because of the
suffering associated with a mental disorder.
Speculative Implication: Impacts of MAID MD-SUMC on the public’s perception and

trust of healthcare practitioners.
Permitting more MAID MD-SUMC may affect public trust and confidence in
mental healthcare practitioners. It may lead to greater trust and confidence if
healthcare practitioners are seen to respect patient autonomy and to observe
the principle of non-abandonment. Alternatively, people with mental disorders
may become more apprehensive about seeking mental healthcare services,
concerned that they will be encouraged to seek MAID. It may also lead to the
public losing some trust in healthcare practitioners who would now be seen
as facilitating or providing death.
Speculative Implication: MAID MD-SUMC and access to mental healthcare and social
supports.
Permitting more MAID MD-SUMC may affect public support for, and
governmental decisions related to, funding for mental healthcare and social
support services for people with mental disorders. It may increase resources
directed to mental healthcare and social support services, as was the case with
palliative care in Oregon, Belgium, Quebec, and the rest of Canada following
legalization of assisted dying (BCSC, 2012; Bernheim et al., 2014; Plante, 2015;
CBC, 2017b). Alternatively, since chronically ill patients who receive MAID
will no longer need services and therefore reduce costs, some Working Group
members believe there may potentially be a counter-productive incentive to
decrease services even further.
Speculative Implication: MAID MD-SUMC and physical risk and trauma for bystanders
and first responders.
If permitting more MAID MD-SUMC reduces suicide (either by offering an
alternative way to die, or because in seeking MAID a person enters treatment),
danger and trauma to third parties may be reduced. Conversely, if permitting
more MAID MD-SUMC changes social norms in a way that increases suicide,
danger and trauma to third parties may be increased. However, there is no
evidence that the legalization of MAID in any jurisdiction has altered rates of
suicide (Section 4.2.3).
6 .3 UN I Q U E CONS I DE R AT I ONS F OR SPEC IFIC POPU LATIONS
The effects of prohibiting or permitting more MAID MD-SUMC will vary

among different gender, ethnic, cultural, and socio-economic populations
in Canada. These variations are the result of differences in the prevalence of
mental disorders among different demographic groups, the lived experience
of people with mental disorders, suicidality, ability to access mental healthcare
and social supports, and interest in MAID (Section 3.5). Issues related to
capacity, voluntariness of request, vulnerability, discrimination, and/or other
factors may arise uniquely for specific populations such as children, seniors,
and institutionalized people. While there are few data on the potential impacts
for most specific sub-populations, the Working Group has identified several
unique considerations, as well as important knowledge gaps related to MAID
MD-SUMC and these populations.
Gender
Women in Canada experience certain mental disorders at a higher rate than
men (Pearson et al., 2013) and are three to four times more likely to attempt
suicide (although men are more likely to die by suicide) (StatCan, 2017c). The
high prevalence of certain mental disorders in women are strongly associated
with women’s greater exposure to several social and economic inequalities,
including poverty, discrimination, and gender-based violence (WHO, 2001)
(Section 3.5).
International experience suggests that permitting more MAID MD-SUMC

in Canada may lead to a greater proportion of women than men requesting
it. Evidence from Belgium and the Netherlands indicates that women access
psychiatric EAS more than twice as often as men in those countries (Thienpont
et al., 2015; Kim et al., 2016). This differs from the gender proportions among
MAID cases in Canada, where men and women have received the procedure
roughly equally (GC, 2017b). It is probable that the greater proportion of
women accessing psychiatric EAS in these jurisdictions is related to their
greater incidence of some of the mental disorders that frequently motivate
psychiatric EAS requests (e.g., depression). Some Working Group members
expressed concern that permitting more MAID MD-SUMC in Canada would
perpetuate the social and economic injustices that lead to greater instances
of mental disorders in women by offering them MAID while these injustices
remain. Other Working Group members believe that, although permitting
more MAID MD-SUMC would not fix those injustices, autonomy should not
be violated to further social change, and Canada can both respect autonomy
and promote social and economic justice. Also, if it is acknowledged that all
decisions are made under conditions of constrained choice (whether due
to social and economic injustices or not), then overruling the decisions of
women who face constrained choice risks having their decisions ignored or
never invited. Further, if the support necessary to make a person’s decisions
meet some threshold of autonomy is unlikely to be provided, then overruling
that person’s decisions amounts to paternalism that compounds that person’s
marginalization and lack of freedom (Section 4.3.2).
Indigenous Peoples
There are disproportionately higher rates of suicide in some Indigenous
communities and Indigenous people are known to face a range of challenges
related to mental healthcare in Canada. Access to adequate and culturally
appropriate mental healthcare and social support is often limited (Section 3.4).
There are also access issues related to geographical location: while 30% of
Indigenous people in Canada live in large population centres and consequently
should have better access to mental healthcare, nearly 39% live in rural areas
(StatCan, 2018a), and may have limited access to formal mental health supports.
In addition, racism within the healthcare system may increase risks of unequal
access for all Indigenous people. Issues related to access may extend to MAID
MD-SUMC; Indigenous people who want MAID may not request it because of
their mistrust of the healthcare system, because healthcare practitioners are not
available where they live, or because healthcare practitioners may not be willing
to provide MAID. On the other hand, poorer access to mental healthcare on
the part of Indigenous people may lead to increased suffering that may result
in them seeking MAID MD-SUMC.
On the whole, it is difficult to assess how MAID MD-SUMC might affect Indigenous
people, since little is known about how diverse Indigenous communities and
individuals view MAID generally. MAID may not be culturally appropriate within
the context of Indigenous views on end of life and end-of-life care (Elders
Circle — Section 1.5.2), or in the context of Indigenous views on mental health
(Section 3.4). The Working Group identified direct Indigenous consultation,
and the incorporation of traditional knowledge, as important areas of evidence
that require further attention and inclusion in the literature, including ongoing
MAID research and assessments.
Sociocultural and Racialized Groups

Immigrant, refugee, ethno-cultural and racialized (IRER) people have lower rates
of mental disorders compared to the general population when investigated as a
single group, but this ignores the diversity within IRER populations (McKenzie
et al., 2016). People in IRER groups face a number of challenges in accessing
mental healthcare services, including cultural barriers and discrimination
(McKenzie et al., 2016; SHS, 2017) (Section 3.5). These barriers may apply to
MAID and would likely apply if MAID MD-SUMC were permitted. For instance,
a study found that patients receiving MAID in the University Health Network
in Toronto tend to be Caucasian (Li et al., 2017).
LGBTQ+ People
The LGBTQ+ population is diverse, but overall at a greater risk of mental
disorders and suicide (Bauer et al., 2010; Benibgui, 2010; Mustanski et al., 2010)
(Section 3.5). No implications for MAID MD-SUMC and this population group
are currently known.
Seniors
Compared to other demographic groups, older adults who request MAID MD-
SUMC may uniquely be eligible for the procedure. While there is an evolving
definition of “natural death has become reasonably foreseeable,” older people
are more likely to satisfy this criterion for two reasons. First, they are more likely
to have frailty, and frailty (and age) have been identified by the Attorney General
of Canada and the Canadian Association of MAID Assessors and Providers
(CAMAP) as factors to consider when determining whether a person’s natural
death has become reasonably foreseeable (Standing Committee on Justice and
Human Rights, 2016a; CAMAP, 2017b). Second, case law suggests that, once
people reach a sufficiently advanced age, their natural death can be considered
reasonably foreseeable even if they do not have a terminal illness (Section 4.1.2).
It is unclear, however, at exactly what age a person can be considered to meet
this criterion. Some Working Group members raised concerns around ageism
and the devaluing of the lives of older people if age alone makes them uniquely
eligible for MAID with respect to the “reasonably foreseeable death” criterion,
and that expanding eligibility for MAID MD-SUMC could further contribute
to this ageism and increase vulnerability in older adults with mental disorders.
In a study of 66 cases of psychiatric EAS in the Netherlands, the proportion of

requests from people aged 70 or above (32%) (Kim et al., 2016) was greater
than the proportion of that age group in the general population (11%) (CBS,
2011). Compared to other demographics, older people are at a greater risk
of social isolation (The National Seniors Council, 2014), and there is some
evidence from the Netherlands that social isolation contributes to individuals
with mental disorders seeking psychiatric EAS (Kim et al., 2016). Additionally,
some Working Group members and others have expressed concerns about
potential over-inclusion of older people in psychiatric EAS in Belgium and
the Netherlands beyond those with a diagnosed mental disorder, as a result of
the acceptance of “tired of life” as sufficient psychiatric suffering (Lerner &
Caplan, 2015). Other Working Group members note that under the laws of
Belgium and the Netherlands, accessing EAS solely due to being “tired of life”
is not permitted; a serious and incurable condition is required in order to
access EAS in Belgium, while suffering has to be from a medical condition in
the Netherlands (Gov. of Belgium, 2002; Cohen-Almagor, 2017; RTE, 2018b).
MAID MD-SUMC requests from older people may occur most often in the
context of dementia, which is more common in older adults as compared to
other demographic groups. Importantly, those who have dementia may retain
their capacity to provide informed consent during the early stages of the disease
(Kim, 2010). Dementia is well accepted as satisfying the eligibility requirements
for EAS in the Netherlands, and the majority of these cases occur while patients
retain the capacity to consent at the time of the procedure (de Beaufort &
van de Vathorst, 2016; RTE, 2016). RANZCP has identified misconceptions
about older adults, PAS and suicide, and the rights of older adults in general
as important issues to consider when considering physician-assisted suicide
(RANZCP, 2016). Further, this organization has expressed concerns about the
impacts of “debates about euthanasia on older persons” as it relates to risks of
suicide (RANZCP, 2016).
Youth (Mature Minors)

While currently prohibited in Canada, the possibility of MAID being accessed
by mature minors warrants discussion. Suicide is the second-leading cause
of death for those in Canada aged 15 to 24, and the leading cause of death
among those aged 10 to 14 (StatCan, 2017c). Because of the significant changes
taking place during adolescence, prognosis of mental disorders is particularly
difficult in young people. Additionally, brain development is not complete until
approximately 25 years of age (Giedd, 2015). Therefore, it is even more difficult
for a clinician to confidently determine whether a minor’s mental disorder is
irremediable as compared to an adult over 25. Finally, the Working Group on
MAID for Mature Minors found that when one considers the natural history
of mental disorders that begin in childhood, it is highly unlikely that a mental
disorder would be deemed irremediable before a capable minor reaches the
age of majority (age 18 or 19 in Canadian jurisdictions).
Submissions obtained through the CCA’s Call for Input expressed concerns
that permitting more MAID MD-SUMC would put psychologically unstable
young people at risk (OCPG, 2017). Some organizations (e.g., Community
Health Nurses of Canada) have suggested that there should be a minimum
age for MAID MD-SUMC that would exclude mature minors (CHNC, 2017).
Additional discussion on MAID and mature minors can be found in The State
of Knowledge on Medical Assistance in Dying for Mature Minors.
Canadian Armed Forces Members and Veterans

Active Canadian Armed Forces members and veterans have higher rates of
certain mental disorders, and may have better access to mental healthcare
services compared to the general population (Fikretoglu et al., 2016; Rusu et
al., 2016; Mahar et al., 2017; Sareen et al., 2017). However, in 2014 the Auditor
General of Canada found that the mental health outreach strategy of Veterans
Affairs Canada was “not comprehensive enough” and the department was not
“adequately facilitating timely access to mental health services” (AGC, 2014).
No implications for MAID MD-SUMC and this population group are currently
known.
Incarcerated People
Mental disorders are prevalent and growing among incarcerated people, and the
suicide rate of those incarcerated in federal facilities is more than seven times
the Canadian average (Service, 2010). The view of suicidality in prisons may
become more complicated should MAID MD-SUMC be expanded. Suicidality
is treated as a risk in correctional settings, and attempts or indications of
attempts may lead to solitary confinement. Incarcerated people may therefore
resist expressing a considered desire to die if they fear being put on suicide
watch and having freedoms curtailed (ICEL2 Satellite Workshop on Medical
Assistance in Dying for Canadian Prisoners, 2017). In addition, as there is
an overrepresentation of Indigenous people in prisons, expanding MAID
MD-SUMC may create a greater risk for Indigenous people in these facilities,
especially Indigenous men.
Canada faces “significant shortfalls” in meeting the mental healthcare needs

of people in the criminal justice system (MHCC, 2012). Therefore, MAID MD-
SUMC may be desired by some incarcerated people with mental disorders, even
if their symptoms could be lessened had they better access to care. These issues
have been highlighted by the Toronto Catholic Doctor’s Guild:
Our current correctional system does not have adequate capacity to

appropriately manage inmates with mental health illness (evidenced
by inhumane solitary confinement duration and substandard
or inappropriate responses to cries for help à la Ashley Smith). If
psychiatric illness is allowed as the sole criteria for MAID, inmates will
be disproportionately affected.
(TCDG, 2017)
Existing Correctional Services guidelines provide operational direction related

to the provision of MAID to people incarcerated in Canadian correctional
institutions (CSC, 2017).
6 . 4 P O TE N TI A L SAF E GU AR DS
In current Canadian law, several MAID safeguards, including both eligibility

criteria and procedural requirements, seek to protect vulnerable populations.
These safeguards prevent eligibility for most people with a mental disorder
as their sole underlying medical condition, despite the procedure not being
specifically prohibited under the current law. Were MAID MD-SUMC more
broadly permitted, however, the modification or addition of safeguards may
help to protect vulnerable people.
Given that experience with psychiatric EAS has now accrued in Belgium and
the Netherlands, the Working Group believes it is useful to consider the
safeguards used in these jurisdictions as well as their effectiveness. Further,
some potential safeguards that have not been implemented anywhere may be
effective in Canada. In some cases, implementing potential safeguards would
require a change in the current eligibility criteria. These additional safeguards
may be worth consideration by policy-makers in their deliberations. Of note, if
safeguards were added that apply only to MAID MD-SUMC, people with mental
disorders seeking MAID MD-SUMC may be required to satisfy more eligibility
criteria or procedural requirements than people with physical disorders who
qualify under the current law. In order for such additional steps to be justified,
it would need to be demonstrated that the safeguards unique to those seeking
MAID MD-SUMC were guarding against risks that are not faced by those seeking
MAID for physical disorders. Differential treatment of those with mental disorders
may be warranted due to unique characteristics of such disorders (e.g., their
impact on capacity, altered decision-making, and perceptions of the future).
Safeguards are aimed at preventing over-inclusion — that is cases where MAID

MD-SUMC should not occur due to ineligibility (e.g., as a result of coercion
or lack of capacity). On the other hand, safeguards might mean capable and
eligible people are unable to obtain MAID MD-SUMC (under-inclusion) or
are forced to navigate unnecessarily complicated or long processes while
experiencing intolerable suffering. In most safeguards, there is an inherent
trade-off between steps to protect vulnerable people and creating unnecessary
delays or impediments (which can also contribute to vulnerability).
In the following section, the Working Group considers nine safeguards for
MAID MD-SUMC and any evidence about their effectiveness while keeping this
trade-off in mind. The discussion of safeguards is meant to inform policy-makers;
the Working Group makes no assumption that the law will be changed, nor do
they endorse or dismiss any particular safeguard. Additionally, the safeguards
listed are not presented in ranked order and the Working Group does not
intend to suggest limits on what policy-makers may or may not do or consider.
Some Working Group members believe that, even with safeguards in place, some
of the previously identified risks of over-inclusion would still not be mitigated
should MAID MD-SUMC be expanded. These Working Group members note
that the safeguards are discussed conditionally in reference to answering the
charge (i.e., if MAID MD-SUMC were to be permitted), and should not be
taken to imply an endorsement of permitting more MAID MD-SUMC. Other
Working Group members believe that, with proper safeguards, that risks of
both over- and under-inclusion could be sufficiently balanced were MAID
MD-SUMC expanded.
6.4.1 Psychiatric Consultation

Clinical assessment of a candidate’s eligibility forms the basis for the primary
safeguard for MAID in Canada. If MAID MD-SUMC were more broadly permitted,
a potential safeguard might include increasing the requirements that form
these assessments. As described in Chapter 5, Belgium and the Netherlands
require additional independent assessment(s) of eligibility for those seeking EAS
when death is not imminent, as is the case for most psychiatric EAS requests.
In Switzerland, there is an informal version of this safeguard in place despite
not being part of the legislation; the Swiss EAS organization EXIT requires that
two independent experts agree that a person is eligible for an assisted death
on the basis of a psychiatric disorder. The repetition and independence of
eligibility assessments offers an opportunity to prevent over- or under-inclusion.
Belgium and the Netherlands also require that assessors have relevant medical
expertise to ensure they are qualified to evaluate the eligibility of those seeking
psychiatric EAS. More specifically, in Belgium, if death is not foreseeable, two
additional independent assessors — at least one of whom has expertise in the
particular disorder (generally a psychiatrist for psychiatric EAS cases) —must
be consulted. In the Netherlands, while only one additional independent
assessor is legally required, the RTE Code of Practice recommends that an
independent psychiatrist be consulted in cases of psychiatric EAS, in addition
to another independent physician.
It is important to note that the role of the physician or nurse practitioner in

determining eligibility for MAID under the current system in Canada is different
in some respects from their role in Belgium and the Netherlands. For example,
under Canadian law, healthcare practitioners evaluate the eligibility criterion
related to suffering in reference to the patient’s subjective perceptions of their
suffering and what conditions for relief the patient considers acceptable. In
Belgium and the Netherlands, a physician must agree that a patient’s suffering
has no prospect of improvement.
Given the challenges of assessing capacity and prognosis in people with mental
disorders who request MAID MD-SUMC, the inclusion of psychiatrists in the
evaluation of psychiatric EAS requests in Belgium and the Netherlands is not
surprising, even if not always followed in practice (Kim et al., 2016; Dierickx et
al., 2017). Although the mandatory inclusion of psychiatrists (or other experts
in the disorder) in the evaluation process may improve the reliability of capacity
assessments, difficulties in prognostication for most mental disorders means
disagreement about incurability and advanced state of irreversible decline will
likely remain among such experts, were this safeguard to be implemented in
Canada. For example, there was disagreement among consulting physicians
in 16 of 66 (24%) psychiatric EAS cases examined in the Netherlands (Kim et

al., 2016). Agreement is not required among consultants in the Netherlands,
and EAS was provided in all of the studied cases where there was disagreement
among consultants. If adopted in Canada, this safeguard could potentially be
strengthened by requiring that all consultants agree a patient is eligible for
MAID MD-SUMC before allowing them to receive the procedure. However,
some Working Group members believe this could potentially lead to unnecessary
delays or impediments for those seeking MAID. Under Canada’s current
MAID law, two independent assessors must agree that a person is eligible
for MAID (GC, 2016b).
As discussed in Chapter 5, recent advisory documents and statements have been

issued in Belgium examining ways to strengthen safeguards related to evaluation.
An advisory document from the Flemish Association of Psychiatry (VVP) and
an organization representing hospitals and institutions in Belgium (Zorgnet-
Icuro) endorses the requirement that at least two psychiatrists be involved in
every case of psychiatric EAS, and that there be two positive recommendations
(VVP, 2017; Zorgnet-Icuro, 2018). The VVP further states that any negative
recommendation also be considered in order to address the issue of doctor
shopping, and that consultation with current and previous key healthcare
practitioners providing care to the patient is essential (VVP, 2017).
Some Working Group members believe that placing additional requirements on

eligibility assessments for MAID MD-SUMC would result in unwarranted steps
not imposed on people with physical disorders who meet the current eligibility
criteria for MAID. Other Working Group members believe that such additional
requirements may be warranted because of the unique characteristics of mental
disorders (such as their impact on capacity, decision-making, and perceptions
of the future). Additionally, as discussed in Section 4.1.4, Working Group
members disagree on whether differential treatment of those seeking MAID
MD-SUMC compared to those making other highly consequential decisions
would be justified by the characteristics of MAID MD-SUMC.
The psychiatric consultation safeguard was considered and rejected by Parliament

in the context of passing federal legislation (Bill C-14) that ultimately applied
mainly to non-psychiatric conditions (SJCPAD, 2016). However, given that
permitting most cases of MAID MD-SUMC would require a change in the existing
law, policy-makers may wish to re-examine the psychiatric consultation safeguard.
Additionally, while the requirement for additional expert consultation in this
context would usually require a psychiatrist, it may also demand consultation
with different specializations or different professions in some cases. Some
Working Group members believe such a safeguard may lead to problems
of unequal access to MAID MD-SUMC if it were more broadly permitted, as

specialists may only be available for assessments in large urban centres. Other
Working Group members note that offering MAID MD-SUMC in a setting where
there are limited or no mental healthcare services raises important ethical
concerns. Specifically, if a person is at risk of seeking MAID MD-SUMC due
to insufficient mental health resources they will also be at risk of receiving an
inadequate MAID eligibility evaluation because of the same lack of resources.
6.4.2 Multi-Disciplinary Evaluation

Explicitly requiring that the examination of a person’s suffering go beyond
medical factors has been proposed as a possible safeguard to ensure a more
thorough evaluation for MAID MD-SUMC. This would entail evaluation
of suffering beyond what is included in the current Canadian law, wherein
suffering is assessed based on the patient’s subjective perceptions of intolerability
and acceptability of treatment. Such a safeguard could include the explicit
requirement that there be a process that considers psychosocial or non-medical
factors that contribute to suffering, such as grief, loneliness, stigma, shame,
or lack of support for the patient or their caregivers. To the extent that some
physicians and nurse practitioners may not have the experience and ability to
effectively evaluate matters such as psychological and cognitive functioning or
social conditions, other experts could be included in the evaluation process.
According to the Canadian Psychological Association (2016), “the assessment
of a person’s capacity to give informed consent, particularly when that person
has a concomitant psychological or cognitive disorder, must be left to those
regulated health providers with the training and expertise to undertake these
kinds of complex assessments,” adding that “when a person presents with a
grievous and irremediable medical condition concomitant with a cognitive
and/or psychological one, the person’s capacity to give consent (should)
be assessed by a regulated health provider whose scope of practice includes
the assessment of cognitive and/or psychological conditions.” As people
seeking MAID MD-SUMC would have a psychological or cognitive disorder,
this recommendation could extend to many MAID MD-SUMC requests. Other
members of evaluation teams have also been proposed; for example, Zorgnet-
Icuro in Belgium recommended including social workers in the assessment of
MAID MD-SUMC requests (Zorgnet-Icuro, 2018).
Some Working Group members believe that placing additional requirements

on assessments of suffering for those requesting MAID MD-SUMC would create
unwarranted steps not imposed on those with physical disorders who meet the
current eligibility criteria for MAID. Other Working Group members believe
that additional safeguards for MAID MD-SUMC may be warranted precisely

because of the unique characteristics of mental disorders (such as their impact
on capacity, decision-making, and perceptions of the future).
6.4.3 Roundtable, Committee, Tribunal, or Judicial Approval

Several organizations have suggested the use of an additional step in the approval
process, be it through a roundtable, committee, tribunal, or judicial approval.
This type of safeguard seeks to provide another means to ensure all aspects
are examined when assessing factors such as capacity, prognosis, and undue
influence on decision-making in those requesting MAID MD-SUMC. Provided
it is well-resourced, an additional approval step could serve this function by
including a broader range of views and perspectives in the assessment process,
and by providing an opportunity to include all information pertinent to the
decision.
Committee approval exists informally in Switzerland, despite not being

prescribed by law, as EXIT requires that any assisted suicide for those with a
mental disorder as their sole underlying medical condition be approved by
their Ethics Commission (EXIT, 2016). The Working Group did not identify
any data related to the approval or rejection of cases by this Commission. In
Belgium, the recent advisory document from the VVP recommends that, while
the patient and three physicians (the one providing EAS and two consultants)
make the final decision about psychiatric EAS, all of the patient’s doctors and
healthcare practitioners should be involved. The VVP suggests that this be done
in a roundtable format to enable the group to discuss the request openly and
jointly, and to weigh all considerations (VVP, 2017). In Canada, the Vulnerable
Persons Standard (VPS) suggests that “expedited prior review and authorization
by a judge or independent body with expertise in the fields of healthcare, ethics,
and law” be required prior to approval for all cases of MAID (VPS, 2017). The
VPS safeguard was considered and rejected by Parliament in the context of
passing federal legislation (Bill C-14) that ultimately applied mainly to physical
conditions (those where death has become reasonably foreseeable) (SJCPAD,
2016). However, policy-makers may choose to consider this safeguard if MAID
MD-SUMC is permitted more broadly.
Some Working Group members believe a disadvantage of requiring additional

approval steps is that the procedure may become burdensome for people who
are suffering intolerably. The risk of unnecessary suffering would increase if
any additional steps were not completed in a timely manner due to an overly
complex process or insufficient resourcing. The issue of burdensome delay may
be different for many potential cases of MAID MD-SUMC compared to other

conditions. Delays in cases where natural death or loss of capacity is imminent
may foreclose eligibility for MAID. In contrast, delays in cases where natural
death has not become reasonably foreseeable (as with most cases of mental
disorders) will not necessarily foreclose eligibility for MAID, although it will
extend the length of time during which a person suffers intolerably. Undergoing
the evaluation process, however, does not preclude continued treatment and
efforts to relieve the person’s suffering. A second potential disadvantage of
prior judicial review in particular is that it may create a barrier to access for
those living on low incomes if access to the courts is not free.
Some Working Group members note that introducing additional approval steps
for people with a mental disorder as their sole underlying medical condition
may mean they would face unwarranted processes not faced by those with
physical disorders who meet the current eligibility criteria for MAID. Other
Working Group members believe that additional approval steps for MAID
MD-SUMC may be warranted because of the unique characteristics of mental
disorders (such as their impact on capacity, decision-making, and perceptions
of the future), the history of promoting liberties without supporting resources
and safeguards leading to adverse outcomes, and the fact that some laws which
already permit special protections of people with mental disorders.
Currently, people with mental disorders have the right to make end-of-life
decisions, such as requesting palliative sedation, refusing artificial nutrition and
hydration, and refusing or requesting the removal of life-sustaining treatment
without additional approval steps. As discussed in detail in Section 4.1.4,
Working Group members disagree on whether differential treatment between
MAID MD-SUMC and other highly consequential decisions would be justified
by characteristics of MAID MD-SUMC.
6.4.4 Involvement of Family and/or Important Third Parties

The inclusion of family or important third parties in the decision-making
process for MAID MD-SUMC is a potential safeguard against the possibility
that a MAID request might not reflect the autonomous wishes of the person
making the request. By discussing the request with the person’s family, assessors
may have greater confidence that the patient’s decision is not the result of
undue influence, either from the symptoms of their disorder or from external
psychosocial factors.
As noted in Chapter 5, the laws in Belgium and Luxembourg provide that

physicians should discuss the EAS request with the patient’s representative and/
or family members unless the patient objects or there are well-founded reasons
for not doing so. Recent recommendations from the VVP and Zorgnet-Icuro
in Belgium strongly suggest that family and significant others be involved in
decisions regarding psychiatric EAS, and that physicians would be unable to
perform their tasks adequately if patients refused to have them included (VVP,
2017; Zorgnet-Icuro, 2018). It is not recommended by these organizations that
family members approve EAS, but rather that their thoughts and feelings be
included in the discussions about the procedure (VVP, 2017).
Some Working Group members note that this safeguard may be viewed as
creating a risk for vulnerable people who do not want their families involved in
the process. There are a variety of reasons why this may be the case, including
familial abuse. Furthermore, requiring patients to allow involvement of family
(or other third parties) if they wish to be evaluated for MAID may violate well-
established legal norms in Canada regarding patient autonomy and privacy;
this safeguard would make MAID MD-SUMC the only medical decision legally
requiring capable people to involve family members. Other Working Group
members emphasize that the safeguard would not necessarily have to be a
requirement, but rather an option for MAID evaluators.
6.4.5 Two-Track Approach During MAID MD-SUMC Evaluation

A process that explicitly includes an examination of other treatment options
has been proposed as a potential safeguard to ensure patients are aware of
these options. Such a safeguard could determine whether a patient’s suffering
might be relieved by other kinds of psychological interventions. Specifically, the
recent advisory document from the VVP recommends that during the process
of evaluating eligibility for psychiatric EAS, physicians should maintain a “two
track” process involving two different psychiatrists: one conducts a thorough
and extended evaluation for MAID eligibility, while the other explores treatment
options with the person requesting MAID from a recovery-oriented perspective
(VVP, 2017). Some Working Group members note that, under current Canadian
law, a patient is not required to accept treatment for the purposes of MAID
eligibility; it is only required that they be informed of the means available to
alleviate their suffering in order to give informed consent for MAID. Other
Working Group members believe that, since expanding eligibility for MAID
MD-SUMC would involve changes to the existing MAID law, it will be up to
policy-makers to consider what (if any) changes in the current law they consider
to be warranted.
6.4.6 Training of Healthcare Practitioners Consulting on

MAID MD-SUMC Requests
Specialized training for healthcare practitioners involved in MAID MD-SUMC
could be used as a safeguard to address the difficulties of assessing factors such
as capacity, prognosis, and undue influence on decision-making in people with
mental disorders who request the procedure. Training and expertise could
be shared through CAMAP, a voluntary organization that already offers tools
and an information library, as well as an online forum for MAID providers
(CAMAP, 2017a). The Canadian Medical Association could also provide such
training, as they already do for MAID across the country, with the exception of
Quebec. The need for better and targeted capacity assessment tools, as well as
education for healthcare practitioners in order to improve their ability to assess
capacity in people with mental disorders, was highlighted by several organizations
in the CCA’s Call for Input. These organizations include the Canadian Bar
Association, the College of Registered Psychiatric Nurses of Manitoba, and the
Nurse Practitioners Association of Canada (CBA, 2017; CRPNM, 2017; NPAC,
2017). It is not clear what training specific to MAID MD-SUMC should contain,
nor how effective it would be as a safeguard given the need for specialty (and
sometimes subspecialty expertise) in evaluating mental disorders.
6.4.7 Waiting Period Between Request and Administration of MAID

The presence of a waiting period between the request and provision of MAID
MD-SUMC is a safeguard intended to ensure that a person’s desire for MAID is
stable rather than impulsive. Such a waiting period could be longer than the
10-day period required in the current Canadian MAID law (GC, 2016b). As
discussed in Chapter 5, laws in Belgium specify that, in cases where a person’s
death is not reasonably foreseeable, there must be a one-month waiting period
between the request and the administration of EAS (Gov. of Belgium, 2002). In
a Belgian study that examined psychiatric EAS, 11 of 48 patients approved for
the procedure postponed or cancelled the procedure after approval (Thienpont
et al., 2015). Eight people explained that knowing they had the option of
psychiatric EAS “gave them sufficient peace of mind to continue their lives,”
two changed their mind “due to strong family resistance,” and in one case,
EAS could not be implemented because the patient was in prison (Thienpont
et al., 2015). A further 38 withdrew their request before a decision was reached
(Thienpont et al., 2015). An even longer waiting period has been suggested for
MAID MD-SUMC cases given the episodic nature of many mental disorders. For
example, recent recommendations from the VVP and Zorgnet-Icuro suggest
a waiting period longer than the current required month, to ensure sufficient
time is taken in evaluating the patient and to ensure the request is persistent
(VVP, 2017; Zorgnet-Icuro, 2018). In one case, the recommendation is for
a waiting period of at least one year (Zorgnet-Icuro, 2018). Some Working
Group members noted such a safeguard would mean that people with mental
disorders would face barriers to accessing MAID not imposed on those with
physical disorders who meet the current eligibility criteria. Other Working
Group members believe that such a safeguard may be needed to accommodate
the unique features of MAID MD-SUMC, if it were expanded.
Some Working Group members believe that adding a waiting period would
delay the provision of MAID MD-SUMC for those who do qualify, thereby
prolonging their suffering. Indeed, in the Thienpont et al. (2015) study, 4%
of those approved for psychiatric EAS (2 out of 48 approved requests) died by
suicide during the waiting period after approval, before the procedure could
be carried out. In at least one case, this was due to the fact that the person
“found the waiting time after the approval unbearably long” (Thienpont et al.,
2015). However, other Working Group members believe that, without sufficient
waiting periods, some people who would change their minds, given enough
time, may receive MAID MD-SUMC. As noted above, in Thienpont et al. (2015),
11 of 48 people (23%) whose requests for psychiatric EAS were accepted
postponed or cancelled the procedure before it was carried out. In addition,
out of 100 total applicants, 38 people withdrew their requests for psychiatric
EAS before a decision was reached regarding their eligibility (Thienpont et al.,
2015). Thus, approximately half of the requests were withdrawn either before
or after a decision was reached.
6.4.8 Agreement on Determination of Treatment Futility

A potential safeguard aimed at avoiding over-inclusion in MAID MD-SUMC
would be to require that both a physician and patient agree on the futility of
treatment. The current MAID law reflects the importance placed upon informed
consent and self-determination with respect to medical decision-making in
Canadian constitutional and common law. Canadian MAID law specifies that the
alleviation of a patient’s suffering is not determined by the availability of effective
treatment, but by whether the patient regards the treatment as acceptable.
Therefore, the patient’s own views about whether a treatment is acceptable
and whether their suffering is intolerable are determinative. This is in contrast
with the approaches in Belgium and the Netherlands where the law requires
that a physician and patient together agree that suffering has no prospect for
improvement based on best current scientific evidence (Chapter 5). The advisory
document from the VVP, citing the 2009 Dutch psychiatric guidelines, suggests
that, while a patient is “entitled to refuse a treatment offering a reasonable
prospect of success,” this refusal should preclude EAS, as it makes it impossible
to then determine that the condition is medically hopeless and untreatable,
and that suffering cannot be alleviated (VVP, 2017). The document argues
that a patient should be deemed untreatable only after all standard biological,
psychotherapeutic, and social interventions indicated for that patient have
been attempted (VVP, 2017).
Whether the Belgian and Dutch approach is a useful safeguard depends on how
one understands the definition of irremediable (Chapter 4), and how one views
the risks of over-inclusion or under-inclusion. Some Working Group members
emphasize that rigorous evaluations of futility may help prevent the over-inclusion
of people whose suffering may be remediable; other Working Group members
note that this may cause under-inclusion by creating unwarranted barriers for
those who are suffering and who view the harms of potentially effective treatment
as unacceptable to them. Canada already permits MAID MD-SUMC based on a
person’s subjective assessment of the intolerability of their suffering, although
few people with a mental disorder as their sole underlying medical condition
will meet all of the other eligibility criteria, such as a reasonably foreseeable
natural death. Some Working Group members argue that if Canada were to
permit more MAID MD-SUMC based only on a person’s subjective assessment of
intolerable suffering and of what conditions for relief they consider acceptable,
it could become the most permissive jurisdiction in the world in terms of how
suffering is evaluated.
In the Canadian context, consent laws are normally considered a matter of

provincial or territorial jurisdiction. It would be up to policy-makers to assess
how to implement a safeguard that requires a physician to concur with the
patient regarding the lack of acceptable treatment options, given the division
between federal, provincial, and territorial jurisdictions over health law.
Years Affected
Uncertainty surrounding the prognosis of many mental disorders has potential
implications for MAID MD-SUMC. However, as noted in Section 3.1.2, the longer
a person has a mental disorder and the better the course of that disorder is
known, the greater confidence a physician may have in the prognosis. Thus, a
possible safeguard could be to limit eligibility for MAID MD-SUMC to people
who have lived with a mental disorder for a certain period of time. This safeguard
would, by its definition, likely exclude minors from obtaining MAID MD-SUMC
even if the minimum age requirement were eliminated. Some Working Group
members note that such a safeguard could extend years of suffering prior to
an individual becoming eligible for MAID MD-SUMC.
6.4.9 Mandatory Reporting and Review of Cases

A mandatory reporting system and review process could together contribute
to a potential safeguard to detect over- and under-inclusion and allow for
an understanding of who is requesting and receiving MAID MD-SUMC. The
regulations around monitoring MAID were released in the summer of 2018 (GC,
2018a). The regulations came into force on November 1, 2018 (GC, 2017a).
The purpose of these regulations is to collect and analyze “data about medical
assistance in dying from a societal perspective” and is not intended to “assess
individual medical or nurse practitioners’ compliance with the Criminal Code
exemptions” (GC, 2018a). These regulations require the reporting of a range
of information including certain demographic factors (age, sex, postal code)
as well as data related to the eligibility criteria. The regulations also require
reporting on findings of ineligibility and withdrawal of MAID requests; this
information would permit the reporting system to detect cases of over- and
under-inclusion. Canada does not currently have an oversight review process
for MAID cases, and the MAID regulations note that issues of non-compliance
with the Criminal Code “falls outside the scope of the federal monitoring regime,
and is under the purview of local law enforcement” (GC, 2018a).
The Benelux countries require that physicians report all cases of EAS to an
oversight committee so that compliance with both eligibility criteria and
procedural elements of the law can be verified (Section 5.7). This oversight
system has detected a very small number of cases where requirements were not
met: 89 cases in the Netherlands and 1 case in Belgium, out of approximately
62,000 combined cases of EAS, from 2002 to 2016 (Mason & Weitenberg, 2015;
Miller & Kim, 2017). These numbers refer to all cases of EAS, not only psychiatric
EAS. The actual number of cases where eligibility criteria were not met may be
higher, however, as there is some evidence that the review committees may not
always make a finding of non-compliance with due care criteria where the rules
were not followed (Kim et al., 2016; Dierickx et al., 2017). In addition, some have
argued that the small number of such cases might not be because the system is
successful at preventing over-inclusion, but rather “because the system is not
designed to, or cannot, provide such strict oversight” (Miller & Kim, 2017).34
Quebec also has a mandatory reporting system, operated through Commission

sur les soins de fin de vie (Gov. of QC, 2014). The Commission’s mandate is to
“examine any matter relating to end-of-life care,” including MAID. Physicians
34 This study examines all “due care not met” EAS cases in the Netherlands, not just those that
relate to psychiatric EAS.
who provide MAID in Quebec must submit a report to the Commission within
10 days. These reports are reviewed to ensure compliance with Quebec’s end-
of-life legislation (Gov. of QC, 2014).
A reporting system in Canada could contain requirements beyond those in

the Benelux countries. It has been suggested that more detailed and accurate
records should be collected in MAID MD-SUMC cases, including data related to
standardized methods for diagnosis and capacity assessment (Lopez-Castroman,
2017). The inclusion of psychiatric expertise on review committees may support
the detection of over-inclusion or under-inclusion related to assessing capacity,
prognosis, suffering, and undue influence on decision-making in people with
mental disorders. Currently there are no psychiatric experts on the Belgian
review committee (Zorgnet-Icuro, 2018), while the inclusion of such expertise
on the Dutch RTE is relatively recent (Onwuteaka-Philipsen et al., 2017).
6 . 5 C O N C LUS I O N
The Working Group brought of range of perspectives on prohibiting or permitting

more MAID MD-SUMC, and through their deliberations and review of the
evidence, identified several potential implications and unique consideration
for specific populations. These implications fell into three categories: (i) those
related to the current eligibility criteria, (ii) vulnerability and autonomy, and
(iii) mental healthcare. Working Group members do not agree on the probability
of each implication occurring, nor on how to balance the evidence supporting
each implication. The above discussion of implications does not present the
consensus view of the Working Group; rather, it is intended to provide policy-
makers with a comprehensive summary of the potential implications (and unique
considerations) related to prohibiting or permitting more MAID MD-SUMC,
as well as a review of the evidence underlying these potential implications.
Several potential safeguards were also identified by the Working Group through
a review of the evidence, including evidence from jurisdictions that currently
allow psychiatric EAS. While the Working Group makes no assumption that
Canadian MAID law will be changed, this examination of safeguards addresses
part of the charge by considering how they may (or may not) help protect
vulnerable people were eligibility for MAID MD-SUMC expanded. As with the
potential implications, the discussion of safeguards is meant to inform policy-
makers, and the Working Group does not endorse or reject any safeguards.
As summarized at the end of Chapters 3 to 5, there are many important

knowledge gaps concerning mental disorders, key issues related to mental
disorders and MAID, and psychiatric EAS worldwide. These knowledge gaps
limited the degree of certainty and level of analysis with which the Working
Group could examine potential implications and safeguards. Moving forward,
continued research and examination of the issues outlined in this report will
help to address some uncertainties and reduce or remove these knowledge
gaps. Ultimately, however, the issue of whether to alter the existing law to
further permit or restrict MAID MD-SUMC is a challenging question upon
which people disagree. While empirical data, legal arguments, and clinical
practice can inform specific aspects of the question, whether or not to further
permit or restrict MAID MD-SUMC ultimately requires ethical judgment by
policy-makers.
Chapter 7 Conclusion 191
7
Conclusion
• Answering the Charge
• Final Thoughts
7 Conclusion
This report answers the charge posed to the CCA by the Ministers of Health
and Justice, on behalf of the Sponsors, Health Canada and the Department
of Justice Canada, as it relates to medical assistance in dying for those with a
mental disorder as their sole underlying medical condition (MAID MD-SUMC).
As noted in Chapter 1, which presents the charge and the evidence considered,
the legislation mandating this independent review and the Sponsor’s charge
used the term mental illness. However, the Expert Panel Working Group chose
to use the term mental disorder in order to be consistent with current clinical and
legal practice, and relied on the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders (DSM-5) to determine the scope of
conditions considered within this report. The Working Group notes that the
term mental disorder covers a diverse and heterogeneous range of conditions,
with distinct clinical profiles and underlying causes. There is wide variability in
symptoms and clinical presentation even within individual diagnostic categories,
and the impact of a mental disorder on a person’s thoughts, emotions, behaviour,
functioning, and quality of life is highly individual. As such, it is difficult to
make any generalizations about this broad category, especially when discussing
potential implications of prohibiting or further expanding MAID MD-SUMC.
Under the current law, people with a mental disorder as their sole underlying
medical condition are not excluded from MAID provided they meet all of the
eligibility criteria. The scope of this report, however, is restricted to those cases
that are not permitted under the current law, as will be the case for most people
whose mental disorder is their sole underlying medical condition.
As requested by the main question of the charge, this report brings together the
available evidence to inform the understanding of MAID MD-SUMC, considering
the clinical, legal, cultural, ethical, and historical contexts in Canada. The charge
also includes a number of sub-questions, the answers to which are summarized
in this chapter. Brief summaries of the questions that were directly answered in
Chapter 6 — which covered potential implications of prohibiting or permitting
more MAID MD-SUMC as well as possible safeguards — are presented first,
followed by answers to the remaining questions, appearing in the order that
they are addressed in Chapters 3 to 5. These three chapters present an overview
of mental disorders in Canada, key issues for mental disorders and MAID, and
assisted dying for people with mental disorders worldwide.
7 .1 A N S W E R I NG T H E C H AR GE
What are the potential implications for individuals and other affected
persons, including their families, care providers, and health
professionals, related to MAID where [a mental disorder]35 is the sole
underlying medical condition?
What are the potential impacts on society of permitting or prohibiting

requests for MAID where [a mental disorder] is the sole underlying
medical condition?
Based on their deliberations and review of the evidence, the Working Group
identified potential implications and impacts related to prohibiting or permitting
more MAID MD-SUMC. Those who could be impacted include people with
mental disorders, healthcare practitioners, people with chronic conditions, and
the family and friends of those with mental disorders. Impacts on society include
those on the mental healthcare system, suicide prevention, and discrimination
and stigma against people with mental disorders.
There is a wide range of potential impacts and implications, and these may
vary depending on the individual as well as on the mental disorder in question.
Furthermore, the Working Group does not agree on the probability of each
implication occurring, nor do they agree on how to weigh the evidence about
each implication. All potential implications and impacts, and the evidence
underlying them, are discussed in Chapter 6.
What are the unique considerations related to individuals living with

[a mental disorder] (including mature minors) requesting MAID
where [a mental disorder] is the sole underlying medical condition,
both in communities and institutions?
The impacts of prohibiting or permitting more MAID MD-SUMC will vary
among different populations based on variations in the prevalence of mental
disorders, the lived experience of people with mental disorders, suicidality,
the ability of people to access mental healthcare and social supports, and their
views on MAID. Many of the knowledge gaps concern what is not known about
MAID MD-SUMC for several population groups.
The Working Group identified Indigenous consultation and the incorporation

of traditional knowledge as important areas of evidence that require further
attention and inclusion by policy-makers and researchers. What evidence exists
35 Original language in the charge was mental illness.

with respect to unique considerations for other specific populations — including

immigrant, refugee, ethno-cultural and racialized groups; women; mature
minors; LGBTQ+ people; seniors; Canadian Armed Forces members and
Veterans; and incarcerated people — are briefly summarized in Chapter 6. The
unique considerations for mature minors are summarized in Chapter 6 and
were considered by the Mature Minors Expert Panel Working Group.
What are the potential risks and safeguards that might be considered
related to requests for MAID where [a mental disorder] is the sole
underlying medical condition?
The main risks of prohibiting or further expanding MAID MD-SUMC relate to
over-inclusion or under-inclusion. Over-inclusion refers to people receiving MAID
in cases where it should not occur (due to ineligibility or undue influence),
while under-inclusion refers to capable, eligible people not being able to receive
MAID. Existing safeguards in Canada’s MAID law prevent eligibility for most
people with a mental disorder as their sole underlying medical condition (as
they do for some people with chronic physical conditions), though there is not a
specific blanket prohibition for people with such conditions. There are a range
of safeguards that could potentially mitigate some of the risks of over-inclusion
were MAID MD-SUMC permitted more broadly, although there is disagreement
among Working Group members about whether safeguards could mitigate
certain risks (Chapter 6). In addition, what is a safeguard to some people might
be a barrier to others, and some safeguards may create a risk that capable and
eligible people are unable to obtain MAID MD-SUMC (under-inclusion). In
Chapter 6, the Working Group considers nine safeguards — including those
currently implemented in Belgium and the Netherlands countries as well as
those that have yet to be implemented in any jurisdiction — and reviews any
evidence relevant to their effectiveness.
What is the impact of mental [disorders] in [their] different forms on

an individual’s legal capacity to request and consent to MAID?
In order to provide informed consent for MAID, a person must have the legal
capacity to make that decision. In Canada, all adults, including those with
mental disorders, are presumed to have the legal capacity to make consequential
medical decisions. This presumption can only be overturned after a formal
capacity assessment undertaken by a healthcare practitioner indicates that a
person’s decision-making capacity is impaired. Moreover, as capacity is always
evaluated relative to a particular decision, a person might have the legal capacity
to make some decisions but not others (Chapter 3).
Most people with mental disorders have the capacity to make highly consequential
decisions about medical treatment. However, evidence shows that some mental
disorders can impair a person’s decision-making and increase their risk of
incapacity. There may also be challenges associated with assessing decision-
making capacity in some individuals with mental disorders, and different
assessors may disagree about whether or not a person is capable. A particular
challenge for some people who request MAID MD-SUMC is that their desire to
die could be a symptom of their mental disorder. Suicidal ideation is a common
symptom of some mental disorders, and some mental disorders can distort a
person’s thoughts and emotions, leading to a desire to die, hopelessness, and
a negative view of the future. It may be difficult for a clinician to distinguish
between a capable person who is making an autonomous decision for MAID
MD-SUMC and a person whose pathological desire to die is a symptom of their
mental disorder that impairs their decision-making.
People with mental disorders undergo capacity assessments with respect to other
highly consequential decisions that are likely to result in the person’s death
(e.g., refusing life-sustaining treatment). However, Working Group members
disagree about whether such decisions are comparable to MAID, partly for
reasons related to the ethical and practical distinction (or lack thereof) between
acts and omissions, or killing versus letting someone die (Box 7.1).
As discussed in Chapter 4, decision-making may be affected by the symptoms of

a person’s mental disorder even when they meet the legal test for capacity. For a
more detailed discussion of the impact of some mental disorders on the capacity
to provide informed consent for MAID and decision-making, see Chapter 4.
What are the relevant gaps in domestic and international knowledge

and research related to requests for MAID where [a mental disorder]
is the sole underlying medical condition?
Given that assisted dying for those with mental disorders is legal in a small
number of jurisdictions around the world, direct evidence on the practice is
limited. Little is known about assisted suicide for mental disorders in Switzerland
and Germany, despite the fact that it does occur in those countries. Thus, most
direct evidence regarding MAID MD-SUMC comes from Belgium and the
Netherlands. Despite decades of research on the practice of psychiatric EAS
in those countries, knowledge gaps exist. For example, there are few data on
the sociodemographic characteristics of people who request and/or receive
psychiatric EAS in Belgium and the Netherlands, beyond gender and age.
Therefore, if more MAID MD-SUMC were permitted in Canada, it is difficult
to predict who might request it. There is also a need for the integration of
patients’ voices in discussions around psychiatric EAS in Belgium and the
Netherlands. Finally, the impact of psychiatric EAS on Dutch and Belgian

physicians and healthcare practitioners, as well as on the family and friends of
those who request this procedure, is not known.
Thus, there is little evidence on the potential impacts of prohibiting or permitting

more MAID MD-SUMC in Canada on affected individuals, or on Canadian
society. Similarly, the potential impact of prohibiting or permitting more MAID
MD-SUMC on the societal perceptions and stigmatization of people with mental
disorders is unknown. As with Belgium and the Netherlands, the inclusion of
patient voices and the views of those with disabilities in discussions of MAID
MD-SUMC in Canada could be an important step in addressing some of these
knowledge gaps. It is also not known how permitting more MAID MD-SUMC
might affect funding for mental healthcare and social support services, nor its
potential impacts on how suicide prevention is practised in Canada.
Finally, there are knowledge gaps related to both the effectiveness and the
legality of certain potential safeguards for MAID MD-SUMC. As some of the
safeguards examined in Chapter 6 have not been implemented anywhere in
the world, there is no evidence on their effectiveness; other safeguards have
been implemented in the practice of psychiatric EAS in Belgium and the
Netherlands, but evidence of their effectiveness is sometimes either lacking or
open to interpretation. Additionally, even if a safeguard has been implemented
elsewhere, its relevance and effectiveness in the Canadian context are unknown.
Important contextual factors include: cultures; geographies; demographics;
healthcare systems; and legal systems such as different laws, differing judicial
approaches, and differences in jurisdictional divisions between the federal
government (which is responsible for the Criminal Code, which sets out the
legal conditions under which MAID is provided) and provincial and territorial
governments (which are responsible for the provision of healthcare and mental
health law).
7 . 2 FI N A L THO U GH T S
Whether to expand, prohibit, or make no changes to the law that governs

MAID with respect to the eligibility of those with a mental disorder as their
sole underlying medical condition is a contentious subject on which there
are differing opinions. The Working Group’s expertise came from a range of
disciplines and experiences that gave each member a unique perspective on
MAID MD-SUMC. Each Working Group member brought their own expertise
to the deliberations, and the assessment process enabled a robust exchange
of viewpoints, which often diverged. Working Group members feel that the
opportunity to participate in a constructive exchange of ideas resulted in a
report that shows the breadth of viewpoints and perspectives on the evidence.
Box 7.1
Working Group Disagreements on Fundamental Issues on
MAID MD-SUMC
Weighing of outcomes
The Working Group disagrees about how to balance two risks: ending the life of
a person with a mental disorder whose condition would have improved and who
would have regained the desire to live, and denying MAID MD-SUMC to a person
whose condition would not have improved and who would continue to live with
intolerable suffering.
How and when to die vs. whether to die

Some Working Group members believe that there is a fundamental difference between
MAID in circumstances where death is reasonably foreseeable, and most MAID
MD-SUMC (where death is not reasonably foreseeable). They see the first instance
as being about changing the timing and manner of death, and the second instance
as being about whether death will occur for those who may have many years still to
live. Other Working Group members believe that it is not clear that this distinction is a
fundamental ethical difference that justifies a different approach to MAID MD-SUMC.
Distinguishing between suicide and MAID MD-SUMC

The Working Group disagrees about whether it is possible to have a valid and reliable
method of distinguishing between individuals who have made an autonomous, well-
considered decision for MAID MD-SUMC and individuals whose desire to end their
lives due to suffering is pathological, and due to a symptom of their mental disorder.
Potential implications of MAID MD-SUMC

The Working Group disagrees about how to interpret and assess the evidence as
it relates to the potential implications of prohibiting or permitting more MAID
MD-SUMC. Differences in how Working Group members view issues such as autonomy,
discrimination, and human rights influenced their interpretation of the evidence. In
particular, the Working Group disagrees about how permitting more MAID MD-SUMC
would affect suicide prevention strategies.
Differences between MAID and other highly consequential decisions

The Working Group disagrees about whether decisions about MAID are different
from other highly consequential decisions (e.g., refusing life-sustaining treatment).
Many of these disagreements relate in part to whether there are ethical and practical
distinctions between a medical professional actively assisting someone’s death,
versus letting the person die through non-intervention.
This divergence and diversity of interpretations and views are important for
policy-makers. At the conclusion of the assessment process, however, there are
fundamental issues on which Working Group members continue to disagree.
These issues are outlined in Box 7.1.
The Working Group agrees on the need for research to understand better, and to
a greater depth, the implications for individuals with mental disorders, healthcare
practitioners, and society of permitting more or continuing to limit MAID MD-
SUMC. This research would be beneficial regardless of whether more MAID
MD-SUMC is permitted or not. Better research can be accomplished through
investments, but also by removing barriers to investigation — for example, by
standardizing reporting requirements across provinces and territories. The
Working Group’s findings also indicate that there are limitations of the current
notions of what counts as evidence in this field of study.
The diversity of expertise and perspectives among Working Group members

has informed and influenced all aspects of this report, and while the final text
is not what any single Working Group member would have produced on their
own, it reflects their collective effort. Although this is not a consensus-based
report, it presents the available evidence related to MAID MD-SUMC, describes
various interpretations of that evidence, and raises different viewpoints on
several important issues. The Working Group hopes that this report will help
inform those policy-makers who will ultimately make decisions relating to
MAID MD-SUMC in Canada.
References 199
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A PPEND IX A : ASSI STED D YING TER MINOLOGY IN J U R ISDIC TION WOR L DWI DE
Jurisdiction Year Terminology Definition Notes

Allowed
Appendix A
Victoria, AUS 2019 Voluntary Assisted The administration of a voluntary assisted dying substance and The Voluntary Assisted Dying Bill was passed in
Dying includes steps reasonably related to such administration. 2017, and will come into power June 19, 2019
at the latest.
Hawaii, USA 2019 Medical Aid in Dying Not explicitly defined; a qualified patient may request and The Our Care, Our Choice Act was signed into
obtain a prescription for medication that they may self- law on April 5, 2018, to take effect on
administer to end their life in a humane and dignified manner. January 1, 2019.
Physician Assisted Death (PAD) or Physician
Assisted Suicide (PAS) are commonly used in
the American media.
District of 2016 Death with Dignity The request and dispensation of covered medications to Physician Assisted Death (PAD) or Physician
Columbia, qualified patients seeking to die in a humane and peaceful Assisted Suicide (PAS) are commonly used in
USA manner. the American media.
California, 2016 End of Life Option: A drug determined and prescribed by a physician for a qualified Physician Assisted Death (PAD) or Physician
USA Aid-in-Dying Drug individual, which the qualified individual may choose to Assisted Suicide (PAS) are commonly used in
self-administer to bring about his or her death due to a terminal the American media.
disease.
Canada 2016 Medical Assistance The administering by a medical practitioner or nurse practitioner
in Dying of a substance to a person, at their request, that causes their
death; or the prescribing or providing by a medical practitioner
or nurse practitioner of a substance to a person, at their request,
so that they may self-administer the substance and in doing so
cause their own death.
Colorado, 2016 Medical Aid-in-Dying The medical practice of a physician prescribing medical Physician Assisted Death (PAD) or Physician
USA aid-in-dying medication to a qualified individual that the Assisted Suicide (PAS) are commonly used in
individual may choose to self-administer to bring about a the American media.
peaceful death.
239

Jurisdiction Year Terminology Definition Notes 240
Allowed
Colombia 2015 The Fundamental The procedure to address the request to exercise the The Ministry of Health and Social Protection
(1997) Right to Die with fundamental right to die with dignity is not explicitly defined. issued a regulation on the fundamental right to
Dignity die with dignity in 2015. The legal judgment
that first recognized such a right in Colombia
occurred in 1997.
Quebec, CAN 2014 Medical Aid In Dying Care consisting in the administration by a physician of
medications or substances to an end-of-life patient, at the
patient’s request, in order to relieve their suffering by hastening
death.
Vermont, 2013 Patient Choice at the Not explicitly defined; physicians are allowed to prescribe Physician Assisted Death (PAD) or Physician
USA End of Life medication to a patient with a terminal condition for the Assisted Suicide (PAS) are commonly used in
purpose of hastening the patient’s death if they meet certain the American media.
criteria, but may not be involved in the administration of the
medication.
Montana, 2009 Physician Aid in Dying Not explicitly defined; in physician aid in dying, the patient — The provision of physician aid in dying is
USA not the physician — commits the final death-causing act by permitted through the Supreme Court of the
self-administering a lethal dose of medicine. State of Montana ruling that found a terminally
ill patient’s consent to physician aid in dying
constitutes a statutory defense to a charge of
homicide against the aiding physician when no
other consent exceptions apply (Supreme Court
of the State of Montana, 2009).
Physician Assisted Death (PAD) or Physician
Assisted Suicide (PAS) are commonly used in
the American media.
Jurisdiction Year Terminology Definition Notes
Allowed
Appendix A
Luxembourg 2009 Euthanasia and Euthanasia: The act performed by a physician, which
Assisted Suicide intentionally ends the life of a person at the express and
voluntary request of that person.
Assisted Suicide: a doctor intentionally helps another person to
commit suicide or to provide another person with the means to
that end, at the express and voluntary request of the latter.
Washington, 2008 Death with Dignity Not explicitly defined; an adult who qualifies may make a Physician Assisted Death (PAD) or Physician
USA written request for medication that the patient may self- Assisted Suicide (PAS) are commonly used in
administer to end his or her life in a humane and dignified the American media.
manner.
The 2002 Termination of Life on Termination of Life on Request: Not explicitly defined. Termination of Life on Request is commonly
Netherlands Request and Assisted referred to as euthanasia and assisted suicide
Assisted Suicide: Intentionally assisting in a suicide of another
Suicide (EAS).
person or procuring for that person the means [thereto].
Belgium 2002 Euthanasia Intentionally terminating life by someone other than the person The Belgium Act only refers to euthanasia;
concerned, at the latter’s request. however, assisted suicide is not expressly
prohibited in criminal law. Both are practised
and are commonly referred to as euthanasia
and assisted suicide (EAS). The Federal Control
and Evaluation Commission on Euthanasia has
stated that it considers assisted suicide to fall
within the definition of euthanasia, and has
approved cases of assisted suicide in Belgium
as meeting legal requirements (Nys, 2017).
Oregon, USA 1997 Death with Dignity Not explicitly defined; an adult who qualifies may make a Physician Assisted Death (PAD) or Physician
written request for medication that the patient may self- Assisted Suicide (PAS) are commonly used in
administer to end his or her life in a humane and dignified the American media.
manner in accordance with the law.
241

Jurisdiction Year Terminology Definition Notes 242
Allowed
Germany – Assisted Suicide Not explicitly defined; suicide is exempt from criminal A 2015 law makes it illegal to assist in suicide
punishment, as is aiding suicide. However, killing a person at the for commercial intent. Relatives or other
express and earnest request of the victim (“mercy killing”) is a persons closely related to the patient who are
criminal offence. only involved as non-business participants are
exempt.
Switzerland – Assisting Suicide Not explicitly defined. Art. 115 of the Swiss Criminal Code (1942)
states: Any person who for selfish motives
incites or assists another to commit or attempt
to commit suicide is, if that other person
thereafter commits or attempts to commit
suicide, liable to a custodial sentence not
exceeding five years or to a monetary penalty.
Sources: Constitutional Court of Colombia, 2014; GC, 2016b; Gov. of Belgium, 2002; Gov. of CA, 2015; Gov. of CO, 2016; Gov. of Colombia, 2015; Gov of DC, 2016; Gov. of Germany, 2015; Gov. of HI, 2018; Gov. of
Luxembourg, 2009; Gov. of the Netherlands, 2002; Gov. of OR, 1997; Gov. of QC, 2014; Gov. of Switzerland, 1942; Gov. of Victoria, 2017; Gov. of VT, 2013; Gov. of WA, 2009; Nys, 2017;
Supreme Court of the State of Montana, 2009
Table of terminology and legal definitions used in euthanasia and assisted suicide law around the world, including notes about commonly used terms in local media
and academic literature when different from the official legal terminology.
Appendix B 243
A P P E N D I X B: S U M M ARI E S OF P R OVINC IAL AND TER R ITOR IAL

M E N TA L HE ALT H AND H E ALT H C ARE C ONSENT LEGISLATION
The following tables contain a list of provincial and territorial legislation that
address mental health and healthcare consent. This list is not exhaustive, and
the distinction between legislation that deals with mental health and legislation
that deals with healthcare consent is not well-defined.
Table B.1
Provincial and Territorial Mental Health Legislation
Jurisdiction Act
British Columbia Mental Health Act, RSBC 1996, c. 288
Alberta Mental Health Act, RSA 2000, c. M-13
Saskatchewan Mental Health Services Act, SS 1984-85-86, c. M-13.1
Manitoba The Mental Health Act, CCSM c. M110
Ontario Mental Health Act, RSO 1990, c. M.7
Quebec Civil Code of Quebec, CCQ-1991, c. 64
Act respecting the protection of persons whose mental state presents a danger
to themselves or to others, c. P-38.001
New Brunswick Mental Health Act, RSNB 1973, c. M-10
Mental Health Services Act, RSNB 2011, c. 190
Nova Scotia Involuntary Psychiatric Treatment Act, SNS 2005, c. 42
Prince Edward Mental Health Act, RSPEI 1988, c. M-6.1
Island
Newfoundland Mental Health Care and Treatment Act, SNL 2006, c. M-9.1
and Labrador
Yukon Mental Health Act, RSY 2002, c. 150
Northwest Mental Health Act, RSNWT 1988, c. M-10
Territories
Nunavut Mental Health Act (Nunavut), RSNWT 1988, c. M-10
Table B.2
Provincial and Territorial Healthcare Consent Legislation
Jurisdiction Act
British Columbia Health Care (Consent) and Care Facility (Admission) Act, RSBC 1996, c. 181
Representation Agreement Act, RSBC 1996, c. 405
Alberta Adult Guardianship and Trusteeship Act SA 2008, c. A-4.2
Personal Directives Act, RSA 2000, c. P-6
Saskatchewan The Health Care Directives and Substitute Health Care Decision Makers Act,
2015, c. H-0.002
Manitoba The Health Care Directives Act, CCSM c. H27
The Vulnerable Persons Living With a Mental Disability Act CCSM, c. V90
Ontario Health Care Consent Act, SO 1996, c. 2 Sched. A
Substitute Decisions Act, 1992, SO 1992, c. 30
Quebec Civil Code of Quebec, CCQ-1991, c. 64
New Brunswick Infirm Persons Act, RSNB 1973, c. I-8
Nova Scotia Personal Directives Act, SNS 2008, c. 8
Adult Capacity and Decision-making Act, SNS 2017, c. 4
Hospitals Act, SNS. 1989 c. 208
Prince Edward Consent to Treatment and Health Care Directives Act, RSPEI 1988, c. C-17.2
Island
Newfoundland Advanced Health Care Directives Act, SNL 1995, c. A-4.1
and Labrador
Yukon Care Consent Act, SY 2003, c. 21, Sched. B
Northwest Personal Directives Act, SNWT 2005, c. 16
Territories
Council of Canadian Academies’ Reports of Interest 245
Council of Canadian Academies’ Reports of Interest
The assessment reports listed below are accessible through

the CCA’s website (www.scienceadvice.ca):
Building on Canada’s Older Canadians on Accessing Health and

Strengths in Regenerative the Move Health-Related Data
Medicine (2017) in Canada
(2017) (2015)
Health Product Risk Aboriginal Food Security Improving Medicines for

Communication: Is the in Northern Canada: An Children in Canada
Message Getting Through? Assessment of the State (2014)
(2015) of Knowledge
(2014)
Board of Directors of
the Council of Canadian Academies*
Margaret Bloodworth, C.M., Chair, Former Federal Deputy Minister and

National Security Advisor (Ottawa, ON)
Paul Allison, FCAHS, Dean, Faculty of Dentistry, McGill University (Montréal,

QC)
Tom Brzustowski, O.C., FRSC, FCAE, Member of the Board of the Institute for
Quantum Computing, University of Waterloo; Member of the Board, Waterloo
Global Science Initiative (Waterloo, ON)
David A. Dodge, O.C., FRSC, Senior Advisor, Bennett Jones LLP (Ottawa, ON)
Chad Gaffield, O.C., FRSC, Professor of History and University Research

Chair in Digital Scholarship, University of Ottawa; President, Royal Society of
Canada (Ottawa, ON)
Chantal Guay, Chief Executive Officer, Standards Council of Canada (Ottawa,

ON)
Eddy Isaacs, FCAE, President, Eddy Isaacs Inc.; Strategic Advisor, Engineering,
University of Alberta (Edmonton, AB)
Jawahar (Jay) Kalra, MD, FCAHS, Professor, Department of Pathology

and Laboratory Medicine and Member, Board of Governors, University of
Saskatchewan (Saskatoon, SK)
Bartha Maria Knoppers, O.C., O.Q., FRSC, FCAHS, Full Professor and Director,
Centre of Genomics and Policy, Faculty of Medicine, Human Genetics, McGill
Lydia Miljan, Associate Professor of Political Science and Chair of the Arts
and Science Program, University of Windsor (Windsor, ON)
Linda Rabeneck, FCAHS, Vice President, Prevention and Cancer Control

at Cancer Care Ontario; President, Canadian Academy of Health Sciences
(Toronto, ON)
Douglas Ruth, FCAE, Professor and Dean Emeritus, Associate Dean (Design
Education), NSERC Chair in Design Engineering, and Director of the Centre
for Engineering Professional Practice and Engineering Education, University
of Manitoba (Winnipeg, MB)
* As of November 2018
Scientific Advisory Committee of the Council of Canadian Academies 247
Scientific Advisory Committee of

the Council of Canadian Academies*
Eliot A. Phillipson, O.C., FCAHS, Chair, Sir John and Lady Eaton Professor of
Medicine Emeritus, University of Toronto (Toronto, ON); Former President
and CEO, Canada Foundation for Innovation (Ottawa, ON)
David Castle, Vice-President Research and Professor, School of Public

Administration; adjunct appointment Gustavson School of Business, University
of Victoria (Victoria, BC)
Sophie D’Amours, O.C., FCAE, Rector of the Université Laval (Quebec City, QC)
Jackie Dawson, Canada Research Chair in Environment, Society and Policy,

and Associate Professor, Department of Geography, University of Ottawa
(Ottawa, ON)
Jean Gray, C.M., FCAHS, Professor Emeritus, Medical Education, Medicine,

Pharmacology, Dalhousie University (Halifax, NS)
John Hepburn, FRSC, Vice-President, Research, CIFAR (Toronto, ON)
Gregory S. Kealey, FRSC, Professor Emeritus, Department of History, University

of New Brunswick (Fredericton, NB)
Malcolm King, FCAHS, Scientific Director Institute of Aboriginal Peoples’

Health at Canadian Institutes of Health Research (Saskatoon, SK)
Stuart MacLeod, FCAHS, Professor of Pediatrics (Emeritus), University of

British Columbia (Vancouver, BC); Adjunct Professor, Community Health and
Epidemiology, Dalhousie University (Halifax, NS)
Barbara Neis, C.M., FRSC, John Paton Lewis Distinguished University Professor,
Memorial University of Newfoundland (St. John’s, NL)
Nicole A. Poirier, FCAE, President, KoanTeknico Solutions Inc. (Beaconsfield,

QC)
*As of November 2018

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The State of Knowledge on Medical Assistance

in Dying Where a Mental Disorder Is the Sole

ASSESSING EVIDENCE. INFORMING DECISIONS.

The Expert Panel Working Group on MAID Where a Mental Disorder

THE COUNCIL OF CANADIAN ACADEMIES

Library and Archives Canada

This report should be cited as:

© 2018 Council of Canadian Academies

This project was made possible with the

The Council of Canadian Academies

The Council of Canadian Academies (CCA) is an independent, not-for-profit

The CCA is also supported by its three founding Academies:

The Royal Society of Canada (RSC)

The Canadian Academy of Engineering (CAE)

The Canadian Academy of Health Sciences (CAHS)

The Expert Panel on Medical Assistance in Dying

The Expert Panel Working Group on MAID for Mature Minors

The Expert Panel Working Group on Advance Requests for MAID

The Expert Panel Working Group on MAID Where a Mental

Message from the Chairs

These reports reflect a particular moment in Canada’s history, in the breadth

With our thanks for this opportunity to serve,

Marie Deschamps, C.C., Ad. E.

Message from the President and CEO

Every CCA assessment focuses on a topic of importance to the Sponsor who

This assessment required care, sensitivity, and wisdom to identify what is

Eric M. Meslin, PhD, FCAHS

Special thanks are extended to Elders Dot Beaucage-Kennedy, Jacqui Lavalley,

Project Staff of the Council of Canadian Academies

Assessment Team: Tijs Creutzberg, Director of Assessments

and: Jody Cooper, Editorial Consultant

Reviewers of the MAID for Mature Minors Report

Priscilla Alderson, Professor Emerita of Childhood Studies, University College

Reviewers of the Advance Requests for MAID Report

B. Lynn Beattie, Professor Emerita, Department of Medicine, University of

Reviewers of the MAID Where a Mental Disorder Is the Sole

Kenneth Chambaere, Assistant Professor, End-of-Life Care Research Group,

Elizabeth Peter, Professor, Lawrence S. Bloomberg Faculty of Nursing and

Report Review Monitors

List of Acronyms and Abbreviations Used in the Reports

ACP Advance Care Planning

2 MAID in Canada: Historical and

3 Mental Disorders in Canada................................................. 33

4 Mental Disorders and MAID — Key Issues.......................... 61

5 Assisted Dying for People with

6 Potential Implications of Prohibiting or

Appendix A..................................................................................... 239

Appendix B..................................................................................... 243

• The Expert Panel

• How to Read this Report

Canada has become one of a small number of jurisdictions to allow some

To meet their obligation, the Ministers of Health and Justice, on behalf of

What are the potential impacts on society of permitting or prohibiting requests

Requests for MAID by Mature Minors

Advance Requests for MAID

To address its charge, the CCA assembled a multidisciplinary panel of 43 experts

Medical Assistance in Dying

(a) the administering by a medical practitioner or nurse practitioner of a