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Should Canada Extend MAID to People with Mental Illness?

A psychiatrist weighs in on a question Parliament will need to settle soon

On March 17, 2021, Parliament passed Bill C-7, which repealed the “reasonable foreseeability of natural death” criterion to allow medical assistance in dying (MAID) for people who might otherwise live naturally, if intolerably, for decades. The bill also excluded from eligibility people with mental illness as their sole underlying medical condition. The exclusion was to be repealed automatically two years later but was deferred by Parliament to 2024 and subsequently deferred again to March 17, 2027.

Mohamad Elfakhani is the chief of psychiatry at the London Health Sciences Centre, Victoria Hospital, and an associate professor in the department of psychiatry at Western University. I spoke with him on issues surrounding MAID for people with mental illnesses.

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Some say that mental health conditions can cause as much suffering and pain as physical conditions.

I don’t know of anything, really, that is as painful as a deep depression. It can be physically painful, with symptoms of low energy, fatigue, the inability to get out of bed, to motivate oneself, to enjoy anything. It’s felt physically: when a patient talks about anxiety, for instance, they describe it as butterflies in the stomach, as nausea. The connection between mind and body is strong. I’ve heard of patients who had been depressed before but who had also experienced a heart attack or a stroke, maintaining that their major depressive episode was more painful than those. It can be.

A doctor never hears a patient say, “I had a heart attack and now I’m suicidal.” They might for a patient with a stroke, if the person lost enough function, maybe. But then depression is part of the stroke experience to the point that, now, prescribing antidepressants is best practice for most post-stroke patients.

MAID is different, as it’s a calculated, planned-out process where a patient feels there’s no more hope for recovery. That can be different than having suicidal thoughts.

The distinction, then, is between an acute pain and a sustained, hopeless one? Many of those I’ve interviewed about MAID, including physicians, mention that much suffering abates when the patient knows they have some control over when and how they go.

The first time I heard that concept, in 2011, way before I’d ever heard about MAID in Canada, I was in my first or second year of residency. A case was presented of a young woman who had picked a date that she was going to end her life, and her family was describing this immense level of comfort that came over her: she was extremely depressed and isolated, and then, suddenly, she was out and walking about and engaging with them. Knowledge of the date she would die gave her a sense of comfort.

The psychiatrist presenting the case described this as the scariest thing one could see as a psychiatrist—when people get to that point of peace—because one feels helpless as a physician. It’s a dangerous spot. A doctor always wants to maintain the hope that they can help the patient. But certain death takes that possibility away.

I don’t think I’ve had a patient who actually ended up acting on the date of their plan, but I’ve had a number of patients that set a date, get to that date, surround themselves with family, and then kick the date down the road another six months. Yet the process gives them a sense of peace, just knowing that they have a date. The process is a protective for them. If they don’t do that, they can fall into a deep depression.

Can you say why that’s possible?

I don’t know how to understand the phenomenon psychodynamically. I’ve not studied it enough. But somehow the explanation lies in hope—a hope of reprieve from the pain—but there is an ambivalence, too, because they also don’t want to necessarily act. Other things in their life are working, to some extent, and so they bring those pieces of their life in on that day to help them keep going.

What do you think of MAID?

I suspect my navigation of it is informed by my own personal stance toward hopeless suffering in my own case and that of my immediate family. My mother passed away. Her heart stopped in the hospital after suffering from pneumonia. The arrests happened four times; three lasted about one minute, but there was one that was eight minutes. That one put her into a coma. Over a two-week period, my father and siblings and I gathered together, spending our days at the hospital. We had to make some tough decisions.

My father wanted all-out treatment. I was the only physician in the group. I had spoken to doctors, looked at the CT scan, reviewed the EEG, got informal opinions from physician friends. I sent information to my friends in radiology, neurology, and neurosurgery. They all told me the same thing, more or less: best-case scenario, she comes out of it with very limited function. She might open her eyes, but she won’t be aware of what’s around her; she’ll have to be fed. We decided a few days before my mother passed to adjust her status to palliative and comfort-focused care. We ultimately felt this was the best step, and a few days later, she passed away peacefully.

Before this experience, MAID always made theoretical sense to me on some level. I’ve encountered cases like patients with myasthenia gravis, for example. They know that they’ll lose all muscle—no stopping it. It’s going to happen. Slowing it down a little bit is possible, but eventually, it affects the diaphragm, and one can’t breathe anymore. I can’t help but feel that I would want MAID for myself in such circumstances. I would want that for my family as well—or at least an early and strong palliative care approach.

Does your preference for MAID being available for someone with myasthenia gravis also apply to someone in a profound depression?

MAID for primary mental disorders is a bit different due to the complication of requiring informed consent and capacity. As a practising psychiatrist, I have personally known multiple patients who have told me, “Thank you for forcing treatment on me when I was ill. I didn’t know what I was thinking. I was going to make some really bad decisions.”

Sometimes they had schizophrenia or mania, but others had depression. Those depressed people wanted to kill themselves, and I, as part of the larger care team, forced them to stay in hospital under watch. Just as we would do if a manic patient wanted to spend all their money. Or a psychotic patient on the ward who was posting photos of themselves online and we had to take their phone away. In these moments, all three patients (and they stand in for many more) fought me. They took me to consent and capacity board hearings and, for example, argued that they wanted their phone back. Or that they wanted their autonomy to spend money. That they wanted to leave.

Yet we properly forced treatment on them. Our faith is that there will come a day when they are better, and that, if there was a videotape of the entire episode, and we showed them like ten hours of themselves, they would say, “Oh my god. Thank you so much for not letting me go.” That’s the hope.

So, that could apply in a case of depression. The simple truth is, a patient might not have capacity to initialize MAID because of the extreme negative thoughts that can come as a result of the depression. One of the symptoms of depression is hopelessness and inappropriate guilt, both very difficult to live with in the moment, but once the depression lifts, those dissipate. The mental health purview is complicated. For MAID to make sense in such a context, a patient would have to be truly treatment resistant in a way, like my myasthenia gravis example.

That doesn’t mean depression isn’t painful; it’s extremely painful. But is it curable? If the person was to be cured later, would they say to you, “I was suffering so much, you should have let me kill myself”? Or will they say, “Thank you. My mind was in such a state”? One could argue either way. But as I said, it’s a tough one to answer because of capacity. Mental health, unlike a heart attack, affects how you see the world, the glasses you see the world through. It gets much more complicated.

The best example that I could give, one that even somewhat convinced me that mental illness could be included in euthanasia programs, was at an ethics talk in 2014—before MAID. An eating disorder case was presented. It struck me as one without a solution. It involved an older person with a long-standing food restriction and multiple purging events a day, and who had tried, at different points, almost all the medications we have: [electroconvulsive therapy] treatment, multiple psychotherapy modalities, and dozens of inpatient treatment programs. Nothing had worked. No doctor could come into the picture and say, “Try this residential program. It’s going to solve it.” She’d retort, “I’ve tried three like that, and I’m still suffering.”

I still find this case to be very interesting because it convincingly shows extreme treatment resistance. But in the circumstance of depression, I don’t know that I’ve seen a comparable case—part of the reason being that many people with treatment-resistant cases end up in suicide. So, I don’t know that I’ve seen extremely treatment-resistant depression. It could be, theoretically.

Because the phrase “treatment-resistant” presupposes a limited number of available treatments, and because new treatments are being developed all the time, at what point could the determination of “treatment resistance” reasonably be made? Appreciating that, unless we see an appellate court ruling, this won’t be addressed legislatively until 2027. If you were in a position to provide an opinion as to whether someone with a mental illness was eligible to receive MAID, at what point could the treatment-resistant threshold be met?

That’s a good point. It’s a good ethics question. There are papers on defining treatment resistance—it’s a whole area of study—but I’m not an expert in the area. That’s why I find MAID for the mentally ill such a difficult topic.

Many patients were disappointed by the decision to delay provision of MAID for the mentally ill, so I don’t mean this in an insensitive way, but collectively, the profession of psychiatry breathed a sigh of relief. A lot of psychiatrists much smarter than I am were very happy to have it delayed. The psychiatrists I know who are experts in the area seem to believe that MAID doesn’t apply to psychiatry, which I find a bit strange.

We have a few people in particular in our department who happen to be more senior, who aren’t particularly religious, and whenever this topic comes up, they’re very clear in their opinion that MAID for psychiatry patients is ridiculous. I don’t see it as ridiculous, but at the same time, I know that psychiatry constitutes a different world than, say, myasthenia gravis. With myasthenia gravis, the outcome is almost guaranteed and the patients are competent.

Mental health patients, at their most unwell, are not considered competent. A manic patient isn’t. A psychotic patient isn’t. A depressed patient is questionable: we rarely deem that people are depressed and competent to make a decision about dying.

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Depression contradicting competence is interesting. Can you say more?

Well, “depressed” and “competent” are somewhat subjective terms in that their determination depends on the decision maker. I should be clear. The depressed patient usually actively seeks treatment because they’re suffering, in contrast with the person with mania or schizophrenia, who often is not actively seeking treatment. This is why we tend, as a disease category, to make the blanket generalization around competence. Speaking very broadly, depressed patients in this formulation have the edge on the others in terms of competence. Yet, again, we’re dealing with the complexities of mental health.

You’re saying, then, that depression is one of the more substantiating mental illnesses, should MAID for the mentally ill be legalized.

Depression will be on there, for sure. Depressed people will ask for MAID, and the argument against it will be more complex than for the person with schizophrenia who comes to us and demands MAID because he believes that if he dies, all of humanity will be saved. That’s a delusion. People have delusions like that.

I’d like to get your response to this quote from an external panel on Carter v. Canada: “At one end of the spectrum, one professor argued that, based on the principles of equality, even if a person’s mental illness rendered them legally incompetent, that incompetence should not disentitle individuals who otherwise meet the Carter eligibility criteria from accessing physician-assisted dying. On the other hand, groups such as the Catholic Health Alliance of Canada argued that mental illnesses should not be included in the scope of the medical condition eligibility criterion.”

I don’t know how much I agree with the first statement. That could mean that if somebody has an intellectual disability, we could kill them. I need to be careful with my rhetoric; I know that MAID isn’t killing per se, but I would nevertheless worry about that piece of it. Capacity is a really important thing to consider. What if someone never had capacity in the formal, legal sense? We might feel that MAID’s what’s best for some people. The capacity issue’s tough.

Before we close, I wonder if I could ask you to venture your impression of a case before the Superior Court of Ontario at the moment, that of a former war correspondent, John Scully. Do you have a sense of how persuasive a case for eligibility could be made there?

A case like Mr. Scully’s is profoundly tragic, and I can understand why he and others might see MAID as a potential answer to such relentless suffering. At the same time, as we’ve discussed, cases rooted in psychiatric symptoms alone highlight the enormous complexity of determining eligibility, especially around capacity and the possibility of future improvement.

In our current system, I think it would be difficult to make a persuasive case for MAID based on mental illness as the sole condition, not because the suffering isn’t real—it most certainly is—but because the law has not yet opened that door. And because psychiatry always carries the hope that treatment or relief may still be possible.

Adapted, with permission, from The Writing on the Wind’s Wall: Dialogues about Medical Assistance in Dying by Kevin Andrew Heslop, a compilation of seventeen perspectives on MAID, published by Guernica Editions, 2026.

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