Editor’s note: This article discusses mental illness, self-harm, suicide and suicidal ideation. It may be triggering to some readers.
Kathrin Mentler knows British Columbia’s mental health system inside and out.
She knows it academically because she’s studying to become a counsellor with the goal of working as a peer support worker. She also knows it personally because she’s experienced rounds of depression and anxiety throughout her life.
Mentler says she has accessed suicide prevention services dozens of times while experiencing mental health crises. She has also attempted suicide more than once and woken up in an intensive care unit, overwhelmed with gratitude for the hospital staff who kept her alive.
“I live with chronic suicidal thoughts but that doesn’t mean I never feel joy in my life,” she says.
This spring Mentler found herself in crisis and took herself to Vancouver General Hospital’s Access and Assessment Centre to get help.
“That day my goal was to keep myself safe. I was thinking of maybe trying to get myself admitted to hospital because I was in crisis,” she says.
Mentler says she told the counsellor she was scared she’d “never not feel horrible.” She also disclosed her history of mental illness and self-harm.
Mentler says the counsellor then told her the mental health system was “completely overwhelmed,” that there were “no beds” and that the soonest Mentler could talk with a psychiatrist would be in November. Or she could talk with the on-call psychiatrist, get committed and end up stuck in a holding room, which she wouldn’t be allowed to leave, while she waited for a bed to become available. Mentler says the counsellor told her the whole system was “broken.”
“It was pretty disheartening and made me feel helpless,” Mentler says. “I’m coming here because I’m looking for help and you’re telling me there is no help.”
That’s when the counsellor asked Mentler if she’d ever considered medically assisted suicide.
Mentler says she was “shocked” and “sickened” because she came to the Access and Assessment Centre for help, “not for recommendations on how to kill myself.”
She says the counsellor explained how MAID worked and said lots of patients asked about it, adding patients don’t “suffer” because they take benzodiazepines before receiving the lethal injection.
Mentler says the counsellor also told her about another patient who had several mental health diagnoses and had been taking several different medications when they’d drowned.
“She said she felt sad but that she also felt relief for this person to pass away,” Mentler says.
The story — and the counsellor’s “relief” — disturbed Mentler. She says it felt like the counsellor was making a judgement that it was better for that patient to have died.
“That made me feel like my life was worthless or a problem that could be solved if I chose MAID,” Mentler says.
Mentler has since filed a complaint with Vancouver Coastal Health and asked for the Access and Assessment Centre to give her her files from that day.
She says the centre released files from several previous visits to the Access and Assessment Centre, but not the specific day she requested.
The slippery slope of MAID expansion
When The Tyee contacted Vancouver Coastal Health to ask about its policies around having counsellors discuss MAID with patients in crisis, the health authority said counsellors may ask about MAID to assess how at-risk patients are for self-harm or suicide.
“For patients who present with suicidality staff are to complete a clinical evaluation with a client and explore all available care options, which may include questions about whether they have considered MAID as part of their contemplations,” the health authority said in an email.
Vancouver Coastal Health added that it adheres to federal legislation, which says people with disabilities or terminal illness can access MAID, and that it “works with patients to ensure they fully understand the steps involved in MAID so that they can make an informed decision.”
MAID is not currently legal for people with mental illness in Canada but that is set to change by March 2024.
MAID was legalized in 2016 with Bill C-39 for people with a “previous and irremediable” sickness whose “natural death” was “reasonably foreseeable.” For example, a patient painfully dying of cancer. This form of MAID is referred to as “track one.”
In 2021, with Bill C-7, a second, more controversial track for MAID was introduced, so that people living with disabilities whose natural deaths are not reasonably foreseeable could also access MAID.
In March 2024 the legislation will expand so people whose sole underlying condition is mental illness can access MAID.
These expansions have been met with heavy criticism from disability and mental health advocates, social workers and experts on mental illness. In 2019 then UN Special Rapporteur for the Rights of Persons with Disabilities, Catalina Devandas-Aguilar, said she was “extremely concerned” people with disabilities may request MAID because they couldn’t access adequate care.
Since then several people have told The Tyee and other media that they’re accessing or considering accessing MAID not because of their disability but because they’re unable to access supports to live a good life.
Dr. Sonu Gaind, chief of psychiatry at Sunnybrook Health Sciences Centre in Toronto, and a professor at the university of Toronto, says making MAID accessible for someone with mental illness is “disturbing” because it’s extremely difficult to assess a patient and make the call as a doctor about whether or not they’ll recover.
Using depression as an example, he says 60 to 70 per cent of patients will fully recover after a year even if they do not use any kind of treatment. He also notes that doctors are only right 47 per cent of the time when they say a patient will never recover from depression — which means “we’ll be wrong more than half the time but we won’t know what half we’ll be wrong for,” when assessing patients for MAID.
This is very different than assessing someone with terminal cancer for MAID, as terminal cancer has a one in 100,000 to one in one million chance of spontaneous remission, he says.
While Gaind is a supporter of track one MAID, he says he is “appalled” to see the safeguards removed for track two.
He points to Health Canada’s recently published Model Practice Standard for MAID which covers the existing policy around accessing MAID due to disability.
In part six the document says a clinician should make sure a patient knows about MAID if they think it would be “consistent with the person’s values and goals of care.”
That’s dangerous because there’s an innate power imbalance between health-care workers and patients, Gaind says, meaning that workers cannot provide information neutrally.
When track two became law in March 2021 there were safeguards in place that called for a patient to be assessed for MAID by two medical professionals with one required to be a specialist in their field, Gaind says. He says the Model Practice Standard, published March 2023, removes the requirement that one assessor be a specialist.
The rationale is that it could be hard to connect with a specialist in a timely way, which could prevent someone from accessing MAID, he says.
“If someone can’t access a specialist who knows how to help them, what does that mean about the care they’ve been able to receive to date?” Gaind asks.
Ableism, racism and poverty
Expanding MAID for people with disabilities and mental illness is sending the message that society would rather see disabled and mentally ill people die than to provide them with adequate resources to live well, says Neil Belanger, chief executive officer of the BC Aboriginal Network on Disability Society and member of Lax Seel Clan in house of Nik’ateen of Gitxsan Nation.
Around 80 per cent of Indigenous peoples in Canada have an income that falls under the poverty line, remote communities rarely have access to mental health services and everyone has to deal with anti-Indigenous racism, especially in social services and the health-care system, Belanger says.
“All things aren’t equal,” he adds. “Until communities are accessible and people have access to health, social and transportation services and we can say we live in an equal society we shouldn’t be offering dying as an alternative,” he says.
Track two of MAID is steeped in ableism and ableism has always been deeply entangled in racism, says Michelle Stack, academic director of the University of British Columbia Learning Exchange in the Downtown Eastside.
“This is a new outfit for an old way of dealing with differences, which started off as eugenics,” she says. Eugenics is the disproven theory that selective breeding would improve the human race. It was used by the Nazis during the Second World War to justify the treatment of Jewish people, disabled people and other minority groups and has also been used to justify colonialism, racism, ableism and other forms of discrimination.
“Instead of offering care, dignity, community and belonging we’ll offer none of those things but give people MAID and call it compassion,” Stack says.
She adds that poverty, racism, homophobia and other social determinants of health can lead to mental illness and that, as a society, we need to “make sure people aren’t suffering because of societal attitudes.”
Track two will disproportionately impact people living in the Downtown Eastside, because that’s a community that deals with a lot of structural oppression, she adds. The neighbourhood also has a large Indigenous population who struggle to find decent housing, and struggle with illnesses related to racism, genocide and residential schools.
“The answer is not to say we’ll give them access to MAID,” she says.
Gaind, Belanger and Stack all also raised concerns about the government’s lack of consultation with Indigenous peoples when forming these policies.
Gaind says he used to be part of the pool of experts the government was consulting for MAID, which used to number around 50 people. The pool has since shrunk to “an echo chamber” of six people, he says.
When passing other legislation, government has created exemptions for First Nations due to a lack of consultation with Indigenous communities, Belanger says. The Accessible Canada Act, for example, requires communities to be physically accessible. But First Nations were given an exemption until 2026 while the government did consultations, he says. With track two there’s a similar lack of consultation and the government is pushing ahead regardless, he says.
Gaind says he fears these decisions are being driven by economic considerations. Creating an exemption for the Accessible Canada Act and pushing ahead with MAID are both “cost saving,” he says.
The finances behind MAID are one of the reasons Tim Stainton, a professor at UBC’s school of social work and co-director for the Canadian Institute for Inclusion and Citizenship, opposes expanding MAID for disabilities and mental illness.
He points to an October 2020 report from the Parliamentary Budget Officer that calculated administering MAID under track one would reduce health care costs by $66.5 million, while track two would create $149 million in savings, representing 0.08 per cent of the total provincial health care budgets for 2021.
“Expanding access to MAID will result in a net reduction in health care costs for the provincial governments,” the report adds.
Stainton says that calculation gets that much “scarier” with the expansions because MAID is accessible for people who were not going to die otherwise.
‘Recognizing real and important differences between people’
The Tyee requested to speak with a pro-MAID expansion advocate group Dying with Dignity Canada, but no one was made available.
Dying with Dignity’s website has a page about “myths and facts.” This page states it’s a myth that “clinicians are inappropriately recommending MAID to patients who are not eligible or as an alternative to treatment.” Clinicians are only allowed to respond to questions about MAID and “only nurse practitioners and physicians involved in care planning and consent processes have a professional obligation to initiate a discussion about MAID,” the page says.
This doesn’t line up with Health Canada’s Model Practice Standard, which says clinicians should bring up MAID if they think MAID would align “with the person’s values and goals of care.”
Gaind says the pro-expansion argument for MAID has always been that people should have the right to choose when they want to die and have a right to die with dignity. He’s also heard the argument that prohibiting mentally ill or disabled people is discriminatory.
But it’s discriminatory to ignore very important differences that affect a person’s ability to meaningfully consent to choosing MAID, he says.
“I’m not legally allowed to drive without glasses,” Gaind says. “That’s not discriminatory. That’s recognizing real and important differences between people.”
In cases such as Mentler’s, when a person is experiencing a mental health crisis, it’s “ludicrous” to say a counsellor is respecting a patient’s autonomy by suggesting MAID, he adds.