Soon after entering medicine in 2005, I realized that I was more interested in the human experience of illness than in the disease itself. I completed a rotation in Medical Oncology while pursuing a combined MD and PhD in Cancer Research at the University of Toronto. The oncologist would talk to the patient about their cancer, their prospects with treatment, and so on—and then they would leave. It was nurses and social workers who stayed to deal with questions like: “Oh my God, what am I going to tell my kids?” I wanted to be around for those conversations. I specialized in cancer psychiatry at University Health Network, or UHN, where most of my patients are battling cancer. What I find most fascinating and meaningful is helping people deal with questions of life and death.
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When MAID became legal in Canada in 2016, hospitals scrambled, trying to figure out how to respond. I’m in the Division of Psychosocial Oncology at UHN, and our department head, Gary Rodin, stepped forward and said that we would be tasked with designing the MAID protocol. He reasoned that our department is used to helping people cope with death—that’s our specialty. They asked if I would volunteer to lead UHN’s MAID framework, and I jumped at the chance.
As head of UHN’s MAID program, I oversaw hundreds of cases. I personally also provided MAID many times. I can’t tell you how many, because I don’t keep track. They’re not trophies—it’s simple care. I see a lot of death: 60 percent of my patient population dies in routine clinical care. I don’t care how I help them die, whether by MAID or by my regular psychosocial care.
Being a MAID provider requires what I call excellent professionalism: my personal values should not matter when it comes to how I assess a patient for MAID. Having said that, my opinion is that we should not be providing MAID for mental disorders—and more broadly, for chronic illness. I don’t think death should be society’s solution to all suffering. Society needs to decide what types of suffering are appropriate to respond to with MAID. If someone is suffering because he cannot afford housing, do we think that death is the appropriate solution for him? If your suffering is because you can’t afford your medicine, or other structural weaknesses, is that a good reason for MAID? I personally feel it is medicalization of suffering, but I am a servant of my country, and I will do what the mandate demands. I’m not sure we have that mandate.
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I am also concerned that the law itself lacks important safeguards for patients. The original MAID law stipulated, among other requirements, that a patient’s natural death must be “reasonably foreseeable”. In 2021, this position was successfully challenged in a court case, which created a second MAID track for people with severe and chronic (but not life-threatening) illness. This year, the law was expanded to include patients for whom the sole reason for seeking MAID is mental illness. The government just announced it would seek a one-year delay in the expansion to allow more time for the health care system to prepare. Delay was the right move. I am part of the team developing the guidelines and training for clinicians, and we need time to finalize and disseminate this. This information and training was not available in 2021, and I think this is why some of the problematic cases have come to the fore.
The stakes are high when you give MAID to someone who would not otherwise die. I was recently on call and had been advised to see a patient admitted to hospital for chronic pain. This patient has a complex medical and psychiatric history, significant trauma and very high psychosocial vulnerability. They are lonely. The patient was told that nothing more could be done for his pain, and so he asked to apply for a maid.
I was not his midwife evaluator, but I was asked to consult as a psychiatrist for depression and suicide. Patients told me that if they didn’t feel so lonely, if they felt that someone cared about them, they could probably tolerate their pain better. I told this patient that I think it would be a great loss to the society if he died because he had contributed and still had a lot to give. In other words, I expressed care, which was everything to this person.
“I expressed caring, which seemed to mean everything.”
I tried my best to advocate getting this person into a study for psychedelic-assisted psychotherapy, which I thought might be very helpful, but I was not successful. There was no way they could afford it privately, as it costs thousands of dollars. It was very morally disturbing to me. This person was ready to receive treatment, but could not access it. I think it would be a tragedy if this lovely person moves on with the maid. As far as I know, this person is now applying for a maid. There is no doubt in my mind that when they apply, they are found eligible and can get it.
That matter hurts me a lot. I have to fight myself not to follow that patient up and advise them: Wait, a study might open up, just give it a little more time. But I can’t take on every patient, and I don’t think society will ever be able to fully fill the gaps in access and resources. The law needs a strict role for the clinical perspective. Right now, the MAID evaluation is a checklist of legal requirements: You must be considered capable of making your own decisions, be over the age of 18 and have a “severe and irreversible” condition, among other conditions. It’s about checking the box. What’s more, MAID assessors usually parachute into a patient’s life: they don’t usually have long-term relationships with them.
Importantly, the law does not require a physician to sit down with a patient and have a meaningful discussion about their death wishes – and what social and societal factors may play a role. I’m trying to put that lens into the education curriculum we’re developing for physicians, but it needs to be written into law to have the weight of a legal requirement.
The MAID track for people without a terminal illness stipulates that the physician “should discuss with the person appropriate and available means to relieve the person’s suffering, and agree that the person has seriously considered those means.” Have done.” I don’t think that’s enough. It should say something like “the therapist has to agree that reasonable efforts have been made Treatment, Practice guidelines and training recommend these, but they are optional, and different jurisdictions and providers will adopt them unevenly.
In the beginning, I had a young patient who had cancer and a 65 percent chance of recovery. This individual refused any treatment, and two other MAID assessors agreed that he met all eligibility criteria, in that he had a serious and irreparable condition – it was irreparable because he did not want the treatment available. This is what the law currently says: unless the patient seeks treatment, their condition is considered incurable – even if there are effective treatments.
But not treating cancer with such a high chance of cure is against the standards of medical practice. The doctors involved were in great moral distress regarding this man’s request for a maid. This person signed a consent for me to share their story, but I feel differently about it than they do. He saw this as an expression of his autonomy; I saw it as dystopian.
This person had organized a goodbye party. He invites all his friends to the hospital courtyard and orders pizza, calling it a reverse birthday party. It was a big gathering of friends. They had about eight people in the room where I was going to manage the maid. He climbed onto the hospital bed, and everyone in the room laid hands on him. There was a lot of crying in the room including his parents.
IV was established and prepared. “This is the last time I will ask you this,” I said. “Are you sure?” He looked at me and said yes. And then the syringes went in one after the other. The whole process usually takes about five minutes, although in this case it took longer than usual because the patient was otherwise young and healthy. After his heart finally stopped, I left the room and did my usual post-med routine: called the coroner, reported the death, and completed the paperwork. We always have social workers and spiritual care available to family and friends, but this time no one asked for additional help. After the coroner cleared everything, they began to leave one by one.
I didn’t regret it before. But when I began to think deeply about how to better safeguard the process, I came to regret ending this young man’s life. I just parachuted in, I didn’t know this patient. And I didn’t take the time to have a meaningful discussion with them. I didn’t sit down and say, “Why don’t you try this treatment? If it’s as bad as you think it’s going to be, MAID will be available.” MAID was very new then, and we were all focused on patient autonomy. Current legislation leaves no room for clinical judgement, and no prerequisites for meaningful dialogue. Had it been so, this man might have been alive today.
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Gaps in legislation become a major problem with mental disorders. It is not at all clear, even to a practicing psychiatrist like me, what to do with a patient with a mental illness who asks to die. I recently had a patient with chronic depression who was considering applying for MAID until we could find an effective treatment. She asked me how the requests would ultimately be evaluated in patients with depression. I said that we have to distinguish between a rational desire to die motivated by depression, and she replied, “But why would I want to die if it wasn’t because of depression?” It gave me pause. At the very least, I think we need to motivate physicians to make clinical decisions – both physician and patient should feel that a reasonable effort has been made to treat. And instead of just checking boxes, we should sit down and have a meaningful conversation about a death wish.
Finally, the phrase “reasonably foreseeable natural death” needs to have a clear temporal time limit in the specified legislation. It was part of the original legislation, which was very Canadian—it was purposefully vague so as not to upset anyone. But in practice, providers have interpreted this to mean anywhere from a few months for a terminal illness to several years for a chronic illness. The MAID track is more secure for people who do not have a reasonably foreseeable natural death, including a 90-day waiting period and the expertise required on the underlying condition of the request. It is not a safe clinical practice for people who probably have years to live to bypass these safeguards.
I think over the years we have forgotten that our role as health care providers is to help patients make the best decisions for themselves. I’m not trying to deny patient autonomy—it’s their decision—but I don’t think I should blindly defend that autonomy. It’s very nuanced because, again, I have to keep my personal value system out of it. Helping someone die, especially when they wouldn’t do otherwise, shouldn’t be a matter of checking things off a list.