Experts disagree over expanding medically assisted dying system by March

Leading experts involved in developing an expansion of Canada's medically assisted dying regime to people whose sole underlying condition is a mental disorder are at odds over whether the expansion should be delayed.

One expert says a delay would ease pressure on the "rushed process" of developing practice guidelines for the complex cases, saying that training modules for practitioners won't be ready until the end of this year or early next year at the earliest. But another expert says more waiting is not necessary.

The system was slated to include such patients beginning next March after a two-year sunset clause built in to a 2021 update to the medical assistance in dying or MAID law.

Despite an expert panel determining that the proper safeguards are in place, the federal government announced last week that it intends to legislate further delay. It has not indicated for how long.

"Not everybody is ready," Justice Minister David Lametti said when he made the announcement.

Madeline Li, a cancer psychiatrist who sits on several MAID-related panels, says the Liberal government is still working on developing the practice guidelines around cases with patients whose only underlying condition is a mental disorder.

She said she was pleased with the decision to delay the expansion, and the delay will allow her and others to "properly develop" the guidelines.

"We really didn't start preparing for this until fairly recently," she said, adding the government didn’t convene its panel to develop the guidelines until the fall. "They've very quickly put it together. It was just a few months ago that this panel was convened to have a first draft."

As of last week, she said, a draft of the guidelines was still under peer review.

"We needed to get the whole thing done by March, so it's been a rushed process, but we haven't actually gone through the evidence-based rigor," she said.

Once they are finalized, Li said the guidelines will be sent to provincial and territorial bodies to be incorporated into regulations, and then built into professional practice through medical colleges.

"All of that was supposed to be done before March, which would never have happened," said Li. "Now we have the time to do that."

Li said that training modules for the expansion are still being developed.

She said a curriculum she is helping to develop would train clinicians to consider the psychological factors driving the desire to die and teach them how to assess vulnerable patients who are contemplating a medically assisted death — and how to centre their thinking on equity and diversity.

"We're probably going to finalize it in the spring for a soft launch," she said. "It won't be ready for hard launch until the end of the year or early next year at the earliest."

Li said once the curriculum is ready, it needs to be disseminated across the country to medical professionals "so that there's some consistency and practice across the country."

"That would not have been done by March," she said.

Jocelyn Downie, a law professor and medical ethics expert at Dalhousie University, does not think a delay is the right decision.

She said readiness should not be determined by every clinician in Canada signalling they are prepared to deliver medically assisted dying to people whose sole existing conditions are mental disorders.

"The clinicians who don't think they're ready to go have a professional obligation not to participate in MAID," she said.

When MAID laws first came into force in 2016, she said not all clinicians were prepared. Protocols were still being developed. Drugs were still being acquired.

"The clinicians didn't provide (MAID), because they didn't have all the things they needed to provide it," she said. "You didn't need a delay in the legislation to prevent that from happening. Clinicians who weren't trained didn't provide MAID."

Downie said she wants a rigorous system, but not one that holds people with mental disorders up to a standard that nobody else is required to meet.

She said medical colleges could have been ready for a spring expansion, technical briefings on practice standards were already underway and educational seminars with clinicians were already on her schedule for March.

"What happens is people are getting ready, they also get their hopes up, and then the goalpost moves, because suddenly you're not ready on some other metrics," she said.

This report by The Canadian Press was first published Dec. 23, 2022.