Question Period Note: Expansion of Medical Assistance in Dying (MAID)- Mental Illness

Former Bill C-7, which received Royal Assent on March 17, 2021, included a sunset clause excluding persons with a mental illness as a sole underlying medical condition from seeking MAID until March 17, 2023.
On February 2, 2023, the Government of Canada introduced legislation, Bill C-39, to extend – by a year – the exclusion of eligibility for MAID where a person's sole underlying medical condition is a mental illness, until March 17, 2024. Bill C-39 received Royal Assent on March 9, 2023. This has allowed time for the dissemination of key resources by clinicians, including the release of a Model Practice Standard for regulating bodies in provinces and territories, an accompanying Advice to the Profession guidance document, and a national accredited MAID curriculum for clinicians.
Despite the work done to support health system preparedness, views by health care stakeholders and the public remain divisive about expanding MAID eligibility in March 2024 for persons whose sole underlying condition is a mental illness.
On October 18, 2023, Bill C-314 was voted down in the House of Commons. The bill proposed permanent exclusion of MAID for persons whose sole underlying medical condition is a mental illness.

The Government recognizes that MAID is a deeply personal choice and remains committed to supporting eligible individuals in having their MAID request considered in a fair, safe and consistent manner, while supporting efforts to protect those who may be vulnerable.
The Government extended the temporary exclusion of eligibility for MAID for persons suffering solely from a mental illness to March 2024.
This has allowed time for the development and release of clinician resources supported by our Government such as a model MAID Practice Standard and an accredited MAID curriculum .
The Government continues to work closely with the provinces and territories and health stakeholders to support the development and uptake of resources for safe access to MAID for people who suffer solely from a mental illness.
IF PRESSED ON THE WORK UNDERTAKEN TO SUPPORT PREPAREDNESS …
Our Government is collaborating with provinces and territories, medical and mental health communities to support system preparedness for the repeal of the mental illness exclusion.
This year, we supported important initiatives including development of a model Practice Standard and Advice to the Profession, and the launch of an accredited bilingual curriculum for MAID clinicians. We also funded two Knowledge Exchange Workshops for MAID assessors and providers and launched ongoing engagement with Indigenous Peoples to understand their diverse views and perspectives on MAID.
IF PRESSED ON THE QUESTION OF MAID FOR PEOPLE WITH MENTAL ILLNESS AS THE SOLE UNDERLYING CONDITION …
The Government recognizes that mental disorders can cause suffering on par with that of physical illnesses.
The Government also recognizes that there are diverse views on MAID and mental illness within the psychiatric community.
Resources such as the Model MAID Practice Standard, Advice to the Profession, and the MAID training curriculum, and additional resources developed by provinces and territories will support the medical and psychiatric communities in being prepared for the upcoming changes to the law.
IF PRESSED ON THE MAID FOR MENTAL ILLNESS AND SUBSTANCE USE …
MAID is an option that is available only for eligible Canadians, and the legislation sets a high bar with stringent eligibility criteria and robust procedural safeguards. The MAID provisions in the Criminal Code are carefully designed to protect vulnerable people, including those suffering from mental disorders including substance use disorder.
To be eligible for MAID, a person must: have a serious and incurable illness, disease, or disability; be in an advanced state of irreversible decline in capability; and, experience enduring and intolerable suffering. The person seeking MAID and the practitioners must have discussed reasonable and available means to relieve the person’s suffering, and agree that the person has seriously considered those means.
The Government has provided significant funding to support mental health and substance use supports and to develop national standards for substance use services.
IF PRESSED ON CONCERNS THAT PEOPLE WILL SEEK MAID AS A FORM OF SUICIDE, ESPECIALLY THOSE WITH A MENTAL ILLNESS …
The legislation sets a high bar for access. Only individuals with severe, long-standing and treatment-resistant mental illnesses will be considered for MAID.
To be eligible for MAID, a person must: have a serious and incurable illness, disease, or disability; be in an advanced state of irreversible decline in capability; and, experience enduring and intolerable suffering.
The person seeking MAID and the practitioners must have discussed reasonable and available means to relieve the person’s suffering, and agree that the person has seriously considered those means. These safeguards for persons not nearing a natural death aim to help practitioners identify and potentially address the sources of suffering and vulnerability that could lead the person to ask for MAID.
The Model MAID Practice Standard indicates that assessors and providers should ensure that a person’s request is consistent, unambiguous and rationally considered during a prolonged period of stability, and not during a time of crisis or suicide ideation.
The Government has provided significant funding to support the launch and implementation of 9-8-8, a three-digit number for suicide prevention and emotional distress.
IF PRESSED ON THE GOVERNMENT’S REACTION TO MEDIA STORIES ALLEGING THAT PEOPLE ARE SEEKING MAID DUE TO LACK OF NEEDED SERVICES …
MAID assessors in Canada are required by their regulating bodies to consider the totality of circumstances of any individual requesting MAID. Safeguards include a minimum assessment period for persons not at imminent risk of dying and a requirement to consult providers with expertise in the requester’s condition.
These safeguards for persons not nearing a natural death aim to help practitioners identify and potentially address the sources of suffering and vulnerability that could lead the person to ask for MAID.
No one can receive MAID solely on the basis of lack of social supports, such as housing and mental health services.
Improving access to social and health services remains a priority and governments are working to address disparities.
On June 22, 2023, the Government passed the Canada Disability Benefit Act to reduce poverty and support financial security of persons with disabilities.
IF PRESSED ON QUEBEC’S RECENTLY PASSED AMENDMENTS TO ITS PROVINCIAL LEGISLATION (ACT RESPECTING END OF LIFE CARE)…
On June 7, 2023, the Quebec National Assembly passed Bill 11, An Act to amend the Act respecting end-of-life care, which amends the MAID-related provisions in Quebec’s existing end-of-life legislation.
It is too early to comment on that legislation. However, the federal government is interested in continued collaboration on this important file with the Quebec government.

MAID LEGISLATION AND MENTAL ILLNESS
In the original 2016 legislation (former Bill C-14), which legalized MAID for persons whose natural death was reasonably foreseeable, the Act required the Ministers of Health and Justice to initiate independent reviews on three particularly complex issues, including requests where the sole underlying medical condition was mental illness.
In 2016, the Government asked the Council of Canadian Academies (CCA) to conduct these independent studies. Following a comprehensive study of this matter, experts in this field could not come to a consensus on this very complicated issue.
Four years later, the Government introduced former Bill C-7, which proposed to expand MAID eligibility to persons whose death was not reasonably foreseeable. As introduced, former Bill C-7 contained a provision stating that mental illness was not considered to be a disease, illness or disability. In other words, requests for MAID based solely on mental illness would not be permitted. As such, no provision for a temporary exclusion was included in the former Bill.
During its study of former Bill C-7, the Senate concluded that MAID requests based solely on mental illness should be permitted, and amended the former Bill to include a temporary, 18 month exclusion of eligibility.
In March 2023, Bill C-39 extended by - one year - the temporary exclusion of MAID eligibility for persons suffering solely from a mental illness.
MAID AND SUBSTANCE USE DISORDER
To be eligible for MAID, a person must: have a serious and incurable illness, disease, or disability; be in an advanced state of irreversible decline in capability; and, experience enduring and intolerable suffering. All three of these criteria must be met for a person to be deemed eligible. Furthermore, the legislation includes enhanced safeguards, which make it a responsibility of the medical practitioner to ensure that an individual seeking MAID is made aware of the supports available to them. The person seeking MAID and the practitioners must have discussed reasonable and available means to relieve the person’s suffering, and agree that the person has seriously considered those means. These safeguards for persons not nearing a natural death aim to help practitioners identify and potentially address the sources of suffering and vulnerability that could lead the person to ask for MAID.
Clinician resources, such as a MAID practice standard and a training curriculum, have been developed to assist clinicians in their assessments of complex MAID requests, such as those that involve a mental disorder. These resources point to the need to assess the person over a period of time and not during a time of crisis to ascertain the durability of the condition and proper capacity to consent. The MAID curriculum includes a module on MAID and mental illness which includes information on substance use disorder.
No one can receive MAID solely on the basis of lack of social supports such as housing and mental health services. All jurisdictions in Canada have a broad range of policies, programs and initiatives aimed at providing health and social service supports to individuals.
Through Budget 2021, the Government is investing $45 million to develop national standards for mental health and substance use services, in collaboration with provinces and territories, health organizations, and key stakeholders. National standards will help to ensure that Canadians receive high quality, (e.g., safe, effective, patient-centred, equitable, and culturally sensitive) evidence-based mental health and substance use services. The Government of Canada is also currently investing $5 billion over ten years to improve Canadians’ access to mental health and substance use services. The investment is being provided directly to provinces and territories via negotiated bilateral agreements to help them expand access to community-based mental health and addiction services.
THE EXPERT PANEL ON MAID AND MENTAL ILLNESS
As a requirement of former Bill C-7, an Expert Panel was appointed by Ministers of Justice and Health to conduct an independent review to consider protocols, guidance and safeguards to apply to MAID requests by persons who have a mental illness. The final report of the Expert Panel on MAID and Mental Illness was tabled in Parliament on May 13, 2022. It included 19 recommendations that provide guidance on the interpretation of the MAID eligibility criteria, application of the legislated safeguards, and the assessment process, as well as advice on measures to improve the functioning of Canada’s MAID regime more broadly.
The Expert Panel found that the challenges people tend to associate with MAID eligibility for persons with mental disorder (e.g., irremediability, decision-making capacity, suicidality and structural vulnerability) are neither unique to requests for MAID from persons with a mental disorder, nor applicable to every requester who has a mental disorder.
A key conclusion of the Panel was that new legal safeguards are not required to ensure that requests for MAID from individuals with a mental disorder are handled safely and appropriately. They noted that the legal framework for MAID already sets a very high bar for eligibility – that existing MAID eligibility criteria and safeguards, when interpreted appropriately and buttressed by existing laws, standards, and practices in related areas of healthcare, can provide an adequate structure for assessing those more complex (track two) MAID requests, including where a mental disorder is the sole underlying medical condition. The key consideration for the Panel was ensuring that practitioners have additional guidance on how to operationalize the existing eligibility criteria and safeguards in the context of mental disorder and other complex MAID requests.
The central recommendation of the Panel was for federal, provincial and territorial governments to facilitate collaboration among regulatory bodies on the development of MAID practice standards. This process was completed in March 2023.
In addition to the collaborative work towards the development of MAID practice standards, provinces and territories, in collaboration with healthcare regulators and MAID communities, have also been working towards preparedness – some creating specific teams, adding resources, updating their practice standards and encouraging training to help clinicians in addressing requests for those more complex MAID cases, and where mental illness is a sole underlying medical condition.
On July 26, 2022, the Ministers of Health, Justice and Disability Inclusion issued a news release on the Government’s progress in implementing several of the Panel’s key recommendations to help prepare the MAID practice community in assessing these complex MAID requests. This progress included: developing a practice standard for MAID; developing a nationally fully accredited MAID curriculum; enhancements to the data collection system under the Regulations for the Monitoring of MAID; plans for Indigenous engagement; and, federally-funded qualitative research on MAID.
PARLIAMENTARY REVIEW OF MAID LEGISLATION
The 2021 legislation also required that a Parliamentary Review be initiated within 30 days following its Royal Assent. It stipulated that the Parliamentary Review must address (but not necessarily be limited to) the topics of mature minors, advance requests, mental illness, the state of palliative care in Canada, and the protection of Canadians with disabilities.
The Special Joint Committee on MAID (AMAD) held three meetings before dissolution. The committee reconvened in April 2022 and, on June 23, 2022, submitted an interim report, specifically focused on MAID where a mental disorder is the sole underlying medical condition. The interim report made no formal recommendations but urged the federal government to support the timely implementation of the recommendations of the Expert Panel.
AMAD’s final report, containing 23 recommendations on all topics under its remit, was tabled on February 15, 2023. On June 15, 2023, the Government tabled its Response to AMAD’s report and recommendations in the House of Commons.
It is anticipated that AMAD will reconvene in 2023 for further study.

In preparing for the repeal of the exclusion clause in March 2024, the Government of Canada, in collaboration with provinces and territories, has supported a range of initiatives towards preparedness, guided by recommendations from the Expert Panel, that include:
- Development of a model MAID Practice Standard designed for use by regulatory bodies and clinicians in addressing complex requests for MAID, including where mental illness is involved (completed March 2023).
- Development and launch (August 2023) of a nationally accredited MAID Training Curriculum.
- Funding a Knowledge Exchange Workshop (June 2023) that included over 40 MAID practitioners, as well as psychiatrists, from across Canada to discuss roles and contributions to the proper assessment and management of MAID where mental disorders are involved, and support local training related to MAID for mental disorders.
- Regulatory amendments to the federal MAID Monitoring System to enhance data collection and enrich research and analysis and reporting back to Canadians (enacted January 1, 2023 with new data to be reported in 2024).
- Early activities on engagement with Indigenous Peoples (online tool launched August 17, 2023, with other Health Canada-led and Indigenous-led activities planned for 2024).