The choice to die

The controversy surrounding Amir Farsoud’s case is not unique. The proposed expansion of Maid, which would allow people with a mental illness such as schizophrenia or depression to become eligible for the procedure, has left some in the healthcare industry concerned.

Dr Sonu Gaind, chief of psychiatry at Toronto's prestigious Sunnybrook Hospital, is one of them.

"We will be providing death by false pretences," he said of the proposed expansion.

Dr Gaind also runs a community-based psychiatric practice in the city’s Bloor West Village area.

In his previous job at Toronto’s Humber River Hospital, where he also led the psychiatry department, Dr Gaind was the physician chairman of the hospital’s Maid team.

While he was cautiously supportive of the new law at the time, he has since changed course.

"The decision to expand Maid to mental illness is completely devoid of evidence," he said, blaming its enlargement on an ideological drive for individual autonomy in choosing death.

"We can no longer distinguish traditional suicidality from what is motivating people’s requests for psychiatric euthanasia."

To be eligible for Maid in Canada, a person must suffer from an irremediable condition. In other words: a condition that will not get better.

"That’s in our law," said Dr Gaind. "And all evidence shows that that is impossible [to know] in any individual case of mental illness.

"That’s a fatal flaw that will, with 100 per cent assurance, lead to people getting Maid that would have otherwise gotten better. We just won’t know which ones."

Dr Gaind said even people who experience lengthy periods of mental illness such as depression can and do respond to treatment.

"Even in those circumstances, we can't make predictions of when the person will or won't get better", he said.

It is an idea shared by the World Health Organisation, which says there are effective therapies for mild, moderate and severe depression, including psychological treatment and medications.

In a statement to The National, Health Canada, the government department responsible for national health policy, said "the safety and security of our most vulnerable people remains at the forefront of our actions as we take a careful and considered approach to the implementation of Maid for persons living with a mental disorder.

"The government of Canada will continue to listen to the experts to ensure that a strong Canadian framework is in place to guide Maid assessors and providers before Maid becomes available to those for whom mental disorders is the sole underlying condition."

While some polls have shown the public favour Maid, one by the Angus Reid Institute, carried out in February 2023, showed only a third of Canadians are comfortable with offering assisted suicide to those with a mental illness. The poll was performed on behalf of conservative think tank Cardus.

But Dr Gaind also questions what is pushing people to request Maid in circumstances of mental illness.

"Very often it’s not just the mental illness. It’s actually all sorts of social suffering like loneliness, poverty, isolation, housing insecurity, feeling like a burden to society," he said.

The latter is something that has actually been recorded as a reason for Maid requests. In 2021, over a third of those who received assisted death in Canada noted a perceived feeling of being a burden on family, friends and caregivers as a reason for wanting to end their life.

Similarly, loneliness or isolation were listed in a little over 15 per cent of cases.

"I don’t think most Canadians would feel comfortable with the idea that we now see death as a treatment for loneliness," Dr Gaind said. "To me, that’s actually appalling and shocking and shameful."

Prominent groups including the UN share some of these concerns. The organisation’s former disability expert, Catalina Devandas Aguilar, former special rapporteur on the rights of persons with disabilities, issued a scathing report on Maid in 2020, after leaving her UN post, warning against "eugenic ideas".

"People have the right to live and die with dignity, but we cannot accept that people choose to end their lives because of social stigma, isolation or lack of access to assistance or services," she said.

Despite concerns surrounding Maid's expansion, other studies suggest a majority of Canadians support the law.

In 2022, an Ipsos poll of 3,500 people showed 86 per cent of those surveyed agree with the Supreme Court’s initial ruling that led to MAID’s establishment.

A second Ipsos poll carried out in January 2023 revealed a strong majority of Canadians support the notion that "with appropriate safeguards, an adult with informed consent should be able to request MAID for a severe, treatment-resistant mental disorder that causes intolerable suffering".

The polls were carried out on behalf of Dying with Dignity Canada, a non-profit organisation that advocates assisted death, including for people with mental illness and mature minors.

On a stormy, thunderous day in Burlington, a city of more than 200,000 people on the banks of Lake Ontario, Bev Heim-Myers speaks poignantly of her memories of her brother, who died from cancer before Maid was a possibility in Canada.

"Maybe people don’t need to suffer intolerably," she said.

Ms Heim-Myers is chairwoman of the Board of Directors for Dying with Dignity Canada, a role she happily carries out free of charge, believing strongly in the cause.

She previously worked to support people affected by Huntington's disease, a degenerative and fatal hereditary brain disorder that devastates the mind and body by breaking down nerve cells in parts of the brain.

One of the patients she helped at the time went on to opt for assisted death.

"He knew what his future was going to be. He walked his father through that future," she said.

"For him it was a way to leave this world surrounded by the people he loved, in the way that he wanted to. And it gave everybody peace of mind."

Ms Heim-Myers’s home, in which she grew up, is covered in photos of her children and grandchildren. The joyful images are plastered on to her living room walls, fridge and even the mug that she sips coffee from.

"We talk about [Maid] at the dinner table," she said. "I talk about it with my children. I let them know it’s part of a planning process for end of life."

For Ms Heim-Myers, access to assisted death is about compassion and respecting people’s decisions.

"It’s about personal choice," she said. "I’m not sure that the human condition means human suffering. I think we need to respect that."

It’s a sentiment shared by Canadian Prime Minister Justin Trudeau. While defending the law at a press conference in 2022, he said Maid is a "deeply personal choice that individuals and families need to make."

When it comes to Maid expansion, particularly with concerns over mental health, Ms Heim-Myers accepts the opinions of experts but also believes there are people who are resistant to treatment and end up suffering for years.

"I understand the concerns but I also understand a person with a mental disorder, who has had multiple hospital visits, multiple treatments and multiple drug regimes that have not helped them, that at some point it’s just an experiment with them," she said. "And at some point, they need to make the best decision for them. It’s compassion."

In Canada, the people who request Maid the most are those suffering from cancer. Data from the Canadian government showed that in 2021, 65.6 per cent of people who received Maid had some type of cancer.

Cardiovascular conditions were the second highest with 18.7 per cent. Respiratory and neurological conditions followed, each with 12.4 per cent. Only 2.2 per cent of Maid cases involved people whose death was not considered reasonably foreseeable.

Meera Burns is a palliative care doctor based between Toronto and Vancouver who works daily with the chronically and acutely sick, up to the end of life.

Supportive of the practice since its inception, she has administered Maid to patients and assessed many more for the procedure.

"My battle is not against death, it’s against suffering," she said. "What intractable suffering means is different to each person and I think Maid respects that. It allows people to decide when enough is enough for themselves."

While she has some concerns about mental health expansion and hopes for strong safeguards to be put in place, she believes many people don’t put those suffering from mental conditions on an equal footing to other types of suffering.

"Having seen patients, the suffering is very real and it’s very equal on both sides," she said.

Maid is most often carried out at a patient’s home, but can also be done in a hospital or hospice. Toronto even has its own MaidHouse, which provides a space for those eligible to receive it, who otherwise have nowhere else to go.

"Usually it’s done with a combination of Propofol and some sort of pain medication," she said. "It doesn’t take more than a few minutes."

Dr Burns said she experienced many emotional and touching moments while helping people end their lives, usually while surrounded by their family "who are very supportive and accepting of it".

"They have all been emotional for me," she said. "It has been a real joy to see patients leaving on their own terms.

"I had one patient say to his wife, right as he was dying 'It’s been a slice, I’ll see you on the other side.'”

Dr Burns said many doctors share their patient’s last words before assisted death.

"There’s levity, there’s gravitas, there’s humour, there’s tragedy. I’ve had a patient that said, 'Let’s blow this pop stand'.

"A woman whose husband had passed away told her children, 'I’m going to dance with your dad now'. My friend had a patient say, 'I just want to take you all with me.'"

"It has been very sweet," she said. "It’s a really beautiful option."

If you or someone you know is in crisis, call Talk Suicide Canada at 1-833-456-4566. Support is available 24 hours a day, seven days a week.
For residents of Quebec, call 1-866-277-3553 or visit suicide.ca.
Free and confidential mental health support is available 24 hours a day, 7 days a week from Wellness Together Canada.