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Opinion Assisted dying – we should learn from what's happening in Canada

Dr Seána Glennon looks at the legislation in Canada and a difficult debate around the rights of those with mental health conditions to end their lives.

THE REPORT OF the all-party Oireachtas Committee on Assisted Dying, published this week, recommends legislating for assisted dying for the first time in the state.

The proposed legislation would permit a person to receive assistance in ending their life if they have been diagnosed with an “incurable and irreversible” medical condition, that will cause their death within six months, and that causes suffering that “cannot be relieved in a manner that the person finds tolerable.”

For a neurodegenerative condition, the period would be 12 months. As the committee’s recommendations now go to the government for consideration, Irish politicians and the public would do well to heed the current controversy in Canada over the prospect of extending assisted dying to those suffering from a mental health condition only. 

How it works in Canada  

Assisted suicide in Canada was decriminalised in 2016 following an earlier decision of the Supreme Court. Legislation was introduced following that decision to provide for assisted dying for people suffering from a grievous and irremediable medical condition that cannot be reversed, for whom death is “reasonably foreseeable”.

In 2019, however, a Quebec court held that limiting access to assisted dying only to those whose death was reasonably foreseeable was unconstitutional. In response, in 2021, significant changes to Canada’s legal regime were introduced – removing the requirement that a person’s natural death be reasonably foreseeable in order for them to be eligible for medical assistance in dying. This change has led to a substantial increase – over 30% in 2022 – in the number of people ending their lives under the law. 
The most recent and highly polarising controversy in Canada concerns the possibility of expanding medical assistance in dying to those experiencing mental illness only. Senator Stan Kutcher has argued that those suffering from mental illness only should be permitted to end their lives if they wish, and that to exclude those people from making end-of-life decisions is discriminatory: “A competent person with a mental disorder who is suffering terribly and persistently should be able to decide how they will choose to proceed with their life.”

While assisted dying for people with mental illness only was due to commence in Canada this month, the Minister for Health, in response to concerns from healthcare providers and disability advocates, has announced a three year delay to allow for a closer examination of the complex issues arising.

The mental illness debate

The issue of access to assistance in dying for reasons of mental illness only throws up a host of ethical issues. Advocates argue that those suffering from a long term mental illness should have the autonomy to make a decision about ending their life just like those with a chronic physical condition and that excluding those with mental disorders is stigmatising.

Many experts, however, have pointed out the serious problems of expanding access to those with a mental health condition alone, noting the difficulty of distinguishing between someone who is suicidal and needs intervention, and someone who is competent to seek assisted dying. Dr K Sonu Gaind, a professor of psychiatry and Chief of Psychiatry at Sunnybrook Hospital in Toronto, argues that it is difficult, if not impossible, for a physician to determine that a mental illness is “irremediable” and will never improve. 
It has also been pointed out that mental illness may often be accompanied by other issues such as poverty and homelessness. In circumstances where adequate and timely housing and mental health services are in many cases unavailable to those in need, the prospect of providing access to assisted dying while these shortcomings and gaps in the system persist is troubling to many.

The University of Toronto law professor Trudo Lemmens points out the tension between suicide prevention and expanded access to assisted dying, noting the recent drive to expand assisted dying in Canada has coincided with long waiting lists for suicidal patients to access basic mental health services. Recent research from Canada has highlighted the problems with the system, including people seeking assisted dying where they have been unable to access the medical, disability and social supports they need; and even out of fear of becoming a burden on their families and friends. 

Ireland’s approach

There is no indication at present that Ireland will introduce medical assistance for those suffering solely from mental illness, and the Oireachtas Committee appears to have carefully considered the Canadian experience and the issues arising.

Access to a dignified death without physical pain on a person’s own terms, where that person is suffering from a terminal medical condition, with the appropriate safeguards, is a welcome development for Ireland.

In the current crises of housing and health, and severe shortcomings in availability of mental health services for those in need, however, we should proceed with caution – especially in considering whether the most vulnerable among us need assistance with dying – or assistance with living. 
Dr Seána Glennon is a lawyer and postdoctoral fellow at the University of Ottawa Faculty of Law.

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