Experts struggle with ethics of assisted death for people with mental disorders

Experts the federal government charged with looking at whether people suffering only from mental disorders should be eligible for medically assisted death couldn't even agree on what evidence is relevant to the question, according to reports tabled in Parliament Wednesday.

There was more consensus on two other issues: whether mature minors should be eligible for assisted dying and whether those facing eventual loss of mental capacity should be able to make advance requests for assisted deaths.

The three issues were examined by working groups created by the independent Council of Canadian Academies, representing some of Canada's most august intellectuals. The government specifically instructed the council to make no recommendations on any of the three issues, so the reports released Wednesday just summarize the "state of knowledge" on the issues and canvass the pros and cons of extending the right to an assisted death to each group.

The government has already indicated it has little intention of expanding the law, which went into effect two-and-a-half years ago.

The reports come just over a month after a Halifax woman with incurable breast cancer, Audrey Parker, opted to end her life earlier than she wanted because she feared she'd eventually lose the mental competence required to seek an assisted death. Parker pleaded with the government to allow people like her to make advance requests for medical assistance in dying.

At that time, Justice Minister Jody Wilson-Raybould said she was satisfied with the law as it is.

"We're not considering changing something in the legislation," she said. "We're confident in the legislation that we brought forward, that it finds the right balance in terms of being able to access medical assistance in dying, protecting the autonomy of individuals to make the appropriate decisions for themselves as well as protecting vulnerable individuals."

The law allows medically assisted dying only for incurably ill adults who are suffering intolerably and are already close to natural deaths. It excludes minors and those suffering strictly from mental disorders and does not allow advance requests.

The law is facing constitutional challenges, based on the fact that it is far more restrictive than the assisted-dying regime sketched out by the Supreme Court of Canada when it struck down Canada's prohibition on physician-assisted suicide.

For Wednesday's report on mental disorders, members of the working group — psychiatrists, a nursing professor and medical and legal ethicists, among others — could not agree on some of the most fundamental questions.

For instance, some believed permitting mentally ill people to access assisted dying "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."

Other members, however, believed that it could "increase mental health stigma because it might bolster the belief that the lives of people with mental disorders are intolerable, not worth living."

The report says the issue is particularly challenging because a desire to die can be a symptom of a person's mental disorder, clinicians disagree on which disorders can be considered incurable, and most of those suffering are not near death.

The report on "mature minors" notes that there is already plenty of jurisprudence establishing that someone under the age of 18 can have the mental capacity and maturity to make end-of-life decisions, such as refusing treatment. It says prohibiting mature minors from receiving an assisted death will eventually be challenged in court and suggests the government needs to balance the need to protect youths from exploitation and coercion while "respecting their rights by avoiding unfair and unethical restrictions."

The report on advance requests says they could "provide comfort and relieve anxiety" for those facing the end of life with diminished competence. However, removing the requirement for express consent immediately prior to receiving an assisted death also raises the possibility that a person's life could be ended against their wishes.

It suggests some safeguards could be developed, such as putting time limits on advance requests and requiring the appointment of a substitute decision-maker.