Consultation 028

About the standard

This consultation closed on Jan. 15, 2024.

Medical Assistance in Dying (MAID) is the administration or prescribing by a physician (MD) or nurse practitioner (NP) of a substance to a person, at their request, that causes death.  In 2021, Bill C-7 came into effect, which expanded the eligibility of MAID to include individuals whose death is not reasonably foreseeable. After being delayed by one year, contingent on the approval of federal legislation, individuals whose sole underlying medical condition is mental illness will become eligible for MAID under Bill C-39 on March 17, 2024. To ensure accurate and timely information with this upcoming change, CPSA is updating our Medical Assistance in Dying (MAID) standard of practice.

What’s changed?

  • Includes references and updated glossary based on the “Medical Assistance in Dying (MAID) in Alberta Guidelines” developed by CPSA and CRNA to ensure alignment across disciplines;
  • Added requirement to follow “Medical Assistance in Dying (MAID) in Alberta Guidelines”
  • Removal of “mental illness as sole underlying medical condition” from list of conditions that are not eligible for MAID;
  • Addition of “Capacity” to Glossary for better alignment with Informed Consent standard.

Collaboration between CPSA and CRNA

In preparation for March, CPSA partnered with the College of Registered Nurses of Alberta (CRNA) to develop the joint “Medical Assistance in Dying (MAID) Alberta Guidelines” to support practice consistency between physicians and registered nurses in Alberta.

As CPSA and CRNA are working collaboratively on the updated MAID Guidelines, you may have also received a request for feedback from CRNA regarding this guideline.

Since the guideline is referenced in CPSA’s MAID standard of practice, after reviewing the guideline you were able to share your thoughts on it AND the amended MAID standard of practice. All feedback that was provided to CPSA, CRNA, or both organizations will be shared to ensure all input is considered.

View the draft standard

For your convenience, the draft standard has clean and marked copies available.

All Resources

Your opinion matters

Changes to CPSA’s Standards of Practice impact your day-to-day practice. Your feedback is important, as it helps us develop clear, reasonable expectations and helpful, applicable resources. We appreciate the time you took and the input you provided.

CPSA regulated members, partner organizations, other healthcare professionals and Albertans were invited to provide feedback from December 12, 2023 to January 15, 2024.

Anonymized feedback will be considered by Council at their March 2024 meeting. Once amendments are finalized and approved by Council, members will be notified by email and The Messenger newsletter.

We respect your privacy

All feedback is subject to CPSA’s Privacy Statement. CPSA reviews all comments before publication to ensure there is no offensive language, personal attacks or unsubstantiated allegations, and publishes them (where consent has been provided) as soon as possible.

Other feedback on this standard

Hamza Riaz

Hello and thank you for gathering feedback related to the MAID standard. I am speaking as a psychiatrist.

Patients with severe personality disorders or treatment resistant depression should NOT be given information on MAID if the request for MAID is made in the context of an acute crisis, or intoxicated state. This should amend the first point of the standard.
There should also be some recognition that MAID should only be offered to mental health patients when GOLD STANDARD treatment (medical, or psychotherapeutic) was tried and failed.
I understand that the hope is that the legislation will capture these limitations, but it is up to our profession to stand up for patient access to the best treatment available.

Sheila Wang

Dear CPSA,

Social determinants of health have an intimate connection with mental health. It is incredibly difficult to maintain good mental health, or manage your mental health condition, if you do not have consistent access to shelter, safety, food, social connections, etc. It is becoming more and more difficult for people to access affordable housing, and inflation is making it difficult for people with limited income to meet all their needs (eg. choosing to spend on food or rent/utilities, but not both as they cannot afford it). It is also difficult for people to access good healthcare - more and more people are without family physicians, wait times in the emergency department are increasing, and mental health supports are limited (many psychiatrists are over-capacity and cannot take on patients long-term, many patients cannot afford to pay for counselling, etc).

Many patients' mental health struggles are a direct result of insufficient social supports and social determinants of health. I worry that patients, who are legitimately suffering, may be motivated to seek MAID due to the social circumstances contributing to their disease. That they will seek MAID because they are unable to find or maintain housing, that they will seek MAID because the healthcare system has failed them and they do not have access to mental health supports, that they will seek MAID because it seems like the only option to ease their suffering because social programs and supports were insufficient.

How is the MAID assessment process structured to prevent social determinants of health from motivating people’s requests? What is being done to safeguard against this?

I understand that mental health conditions can be incurable and resistant to conventional treatment, and that there are patients who seek MAID without being influenced by social determinants of health. I do not want to restrict MAID for these patients. I am concerned that there will be vulnerable patients who see MAID as their only option because of poverty and their social circumstances.

I implore the CPSA to consider these patients, and to thoroughly review the eligibility criteria and processes.

Lisa Burback

Dear CPSA colleagues,

I know that you are constrained by the current Federal governmental regulations and policies, and the following is not aimed at any of you who are doing your best. I also respect my colleagues who are supportive of MAID, despite my fervent disagreement with the concept. However, I want to stand in solidarity with other physicians who are raising concern about MAID. I agree with them that it is completely unfathomable that people with mental disorders associated with emotional dysregulation and suicidal ideation (e.g. severe depression, personality disorders, trauma-related disorders, etc) are being allowed to undergo MAID without a) the requirement of a psychiatric evaluation, b) exhausting potentially effective treatments, and c) creating a better system so people can access needed supports and treatments. I have already been told by multiple patients with limited access to such supports and treatments that they will apply for MAID if they can't find appropriate psychosocial supports. A few pertinent examples of frustrating system issues include a) I cannot access publicly funded ketamine for treatment resistant depression within AHS, despite being a psychiatrist employed within the system (but I can refer to private clinics that are not covered and my patients cannot afford), b) the clinically recommended treatments for PTSD (which is frequently associated with suicidality and depression) are not practically available in our publicly funded system (e.g., CPT, EMDR, PE), and b) homelessness and food/housing insecurity is at an all time high.

I do appreciate the standard for conscientious objection. The only issue I have is following wording, with respect to MAID, as I don't think it applies: "These expectations accommodate the rights of objecting physicians to the greatest extent possible, while ensuring that patients’ access to healthcare is not impeded." The Merriam Webster dictionary defines healthcare as "efforts made to maintain, restore, or promote someone's physical, mental, or emotional well-being". While MAID is a health system service, I don't think it applies as healthcare. It is NOT a treatment for an illness; it is purposely facilitating death in someone who would not ordinarily die. MAID stands for Medical Assistance in Dying. The original intent for MAID was to reduce suffering of those who are in the process of dying (e.g. terminal cancer). Now it has expanded to mental illnesses where the person would NOT die, nor do we know if they would have recovered in the future. We are not "assisting" death anymore. We are being asked to participate in something very different.

Further, we cannot accurately predict whether someone will recover from a mental illness. I have personally observed recoveries that others would not have predicted. I have worked with many patients with longstanding treatment resistant illnesses and chronic suicidal ideation. I see unacceptable risk for vulnerable people to fall through the cracks. I also see improvements to mental health treatment on the horizon. Why are we fighting against "discrimination" based on diagnosis (ie. disallowing mental illnesses as a reason for MAID) but we are not fighting against the discrimination that has occurred for decades related to mental illnesses (funding and resources for appropriate access to evidence based mental health care treatments).

I agree wholeheartedly with my colleagues Dr. Hamza Riaz and Sheila Wang and others who see the enormous problems with MAID for mental illness.

Lisa Burback, MD

Tannis Arychuk

Sadly, MAID will tarnish the profession's culture and "death doctors" will emerge. It will become an increasingly sought after quick fix. Access to counselling that is available and affordable is the glaring obstacle that could alleviate much suffering and be the effective alternative. If physicians are placed in a vulnerable position where they feel unable to conscientiously object to being a participant, more will transition away from front line family practice.

Dr. Rob Greidanus

I am deeply concerned that someone that has a mental illness causing suicidal ideations will end up consenting to MAID while they are unwell and in their vulnerable state. These same type of patients have previously been certified under the mental health act and forced to have psychiatric treatment against their will due to the fact that they have a mental illness causing an altered sense of reality and self worth and were a threat to themselves. These policies now stand in conflict. How can the physician be really certain these patients are of sound mind and are truly giving informed consent rather than just helping them act on suicidal ideations from an inadequately treated mental illness? This is a very vulnerable group of patients and physicians as well as the CPSA have an ethical obligation to protect and advocate for their health and appropriate treatment. This is coming at a time where there is a major deficiency in Mental health resources and access in Canada. Who is going to safeguard that this doesn't become the 'easy out' for patients suffering from mental illness but are not able to access appropriate treatment? Many more safeguards need to be in place. I am deeply concerned and disappointed that my profession would be in support of Bill C-39 and would enable it being put in to practice with this policy!

Carmen Wiancko
Physician Assistant

I may not have the exact PC words here, but by nature, some mental health conditions may mask the person's desire to keep living, and wanting to suicide may be a real symptom that can be treated.
For example, depression can be diagnosed using a screen that questions about hopelessness, among other difficult emotions. Hopelessness could be the very emotion tied to wanting to use MAID, but would the person feel the same if they were successfully treated?
Of course we are talking about competency and checks and balance to know the patient has been offered all possible treatments- being not that familiar with MAID, my question would be: How rigorous are the screenings for competency and identifying if all treatment options have been explored?

Steve Garry

I have read many of the comments made by other physicians. I don't need to re-write what others have stated so clearly so I will simply make my support known for the comments made by Dr. Lisa Burback. MAID is not "healthcare" and physicians should not be involved in aiding the death of individuals. I'm vehemently opposed to the concept and feel it is a terrible mistake for the government to take the position that it is morally acceptable to end one's life prematurely.

This is a concept that will devalue life and using "mental illness" as a reason will put us one more step down the slippery slope.

Darryl Rolfson

Mental Illness, unlike other forms of illness, has the potential to impair the judgement and insight of the individual in a temporary or progressive way. It would be a grave error to remove mental illness as a reason not to provide MAID.

Without question, allowing MAID in persons with active mental illness does place constraints on their autonomy However, there is often tension between competing ethical principles when there is borderline competency. Autonomy must be constrained by the principles of non-maleficence (do no harm) and beneficence (act in the best interests of another person).

MAID has already placed greater emphasis on autonomy (ie. expressed wishes of the individual) at the expense of the other two ethical principles. The effect of this has been to shift the burden of moral distress to care providers who must suppress their impulses to act in the best interests of their patients in order to silently follow the expressed wishes of their patient (ie. to proceed with MAID).

Removing mental illness makes this moral distress much sharper. Two examples are suicidal ideation in depression, and poor insight and judgement in dementia. Care providers are trained to recognize these illness presentations and formulate the underlying mental health issues that cause them. However, lifting prohibition of MAID in persons mental illness would disrupt clinical assessments, and create intense moral distress when caregivers cannot be confident that the choice for MAID is informed and exercised by a competent individual.

Linda Der

I have concerns that MAID is to be applied to mental health patients in a short few months... many of our depressed patients who are suicidal improve with time and treatment. I fear MAID may be granted to a patient that has a fully treatable condition.

David Lounsbury

Dear Colleagues,

I would like to echo and support some of the objections raised by others with respect to extending (so-called) MAID to mental health patients in such an unfettered fashion.

1. By definition, insight is lacking in such patients (at least when they are acutely unwell). We often advise people "not to make major decisions" when they are in emotional or traumatic states. Choosing to end your own life must surely fall under such an umbrella. Would we let an acutely suicidal or psychotic person apply for a bank loan or change the terms of their will?
2. Pragmatically, even for a physician who is theoretically completely neutral on this topic, such situations (MAID in the context of mental health disorders) seem to be inherently confused. Typically, a suicidal patient is the "code blue" of Psychiatry. It is our moral duty as doctors to try and "talk people off the ledge" ... to link them to supports, to medicate if needed, to form / restrain if needed, but most of all, to use our shared humanity to try and shed light on the dignity inherent in all human life.
3. (Yes, this next point is a slippery slope argument, but it should still be considered.) People in crisis often feel like (and sometimes actually ARE) a burden to those around them. Despite this, we try to respect and help even our "weakest" members of society. By having "let us help you die" as an option, we are codifying and admitting to this burdensomeness as a society and might actually seem to be promoting death as "the answer" for their existential angst.
4. Unique to my current field (correctional medicine) ... incarceration in many ways is a guaranteed "poor quality of life" (especially at higher security levels). To the extent that MAID is widely adopted in our prison populations, is this not just Capital Punishment by another name?

Respectfully submitted.

Rick Schow

AS a Canadian I am so ashamed to be part of a nation where we lead the entire world in physician-assisted death. There is absolutely no excuse to venture down the death road at virtual break-neck speed. Yet the ruling socialist/NDP/Liberal coalition seems to delight in what they take so much delight in death of Canadians. Right along with abortion, the Trudeau/Singh socialist regime is a murderous regime like no other in the western free world. Shame on every elected official who shares the stain of murder like never before!!

Jill Wiesinger

Expanding MAiD in Alberta - to include those whose sole presenting condition is that of mental illness, is not progress. This exhibits a lack of acknowledgement and a lack of respect of the longstanding Hippocratic Oath ‘to do no harm’.

‘Regulated professionals’ (doctors and nurse practitioners), should not be placing themselves, or required to place themselves, (along with collaborating pharmacists), in the position of playing God, in the lives of those with mental illness, rightfully needing ongoing therapy and medical treatment, over a lengthy period of time. Is the expansion of MAID intended to rid society of those who require on-going treatment, thereby reducing costs to the medical system?

Mental illness is in crisis proportions in our Canadian society today , especially after the heartless restrictions of the pandemic - involving isolation, job losses, medical discrimination of unvaccinated individuals, and a loss of informed consent, this all being fueled by government backed media indoctrination, and resulting in forced vaccination of the majority of Canadians - with an experimental medical treatment.

The expansion of MAID in Canada, is ripe to be the next pandemic, meaning it’s setting the stage for another massive trauma to the Canadian public, leading to a needless loss of innocent lives, of the most vulnerable in our society.. We can do better than this in Alberta, even if it means pushing back at Ottawa, against their Draconian new bills.

My hope is that the majority of doctors, nurse practitioners, and pharmacists in Alberta - will be courageous, and will refuse to participate in this evil agenda, while upholding their constitutional right to ‘freedom of conscience and freedom of religion’.

The regulated professionals in Alberta have every right to treat their patients with mental health conditions proactively, to ‘do no harm’, and to resist policies that are life-threatening to their patients, and demoralizing to themselves as professionals.

I support every regulated professional, including collaborating pharmacists, who refuse to endorse the expansion of MAID in Alberta, and who decline to participate at all - in the euthanizing of their patients..

Jill Wiesinger

To the CPSA: Thank you for being open to feedback. Regarding the potential MAID expansion, why there is such a rush on pushing through the agenda to make MAID available to those suffering with mental illness? Even though Ottawa has sadly taken the lead on this - with passing Bill 37 - maybe it’s time for Alberta’s CPSA to stand up to the bullies in Ottawa???
Rushing the killing of some of the most vulnerable - (feedback can only be given to the CPSA until January 15th) - does not reflect a humane society.
On another related note, there
has been very little said about the following - in the mainstream media, or by the Colleges of Physicians and Surgeons across Canada, but compared with the year 2019, (before the pandemic), and (before vaccine mandates), there is currently - (most recent studies) - a 400% increase in deaths of all causes worldwide. If this is the case, (which in fact it is) - again I ask, why is there an obsession with deleting the lives of some of the most vulnerable Albertans at this time? Albertans are already dying at a 400% greater rate than 4 years ago. Yesterday I talked with an Alberta citizen who had lost five family members in the last year - between hers and her husband’s extended families. The people dying are not all elderly people either; many are younger. We are sadly living in a death culture in Canada. Troubling those already struggling with mental illness, with the thoughts of an early, untimely death, and intentionally placing those thoughts in their - at times - unstable minds, is an unspeakable crime. It’s time that the Colleges of Physicians and Surgeons of Alberta stand up to Ottawa, and not wait to be spoon fed by them. The focus of the CPSA needs to be to begin immediately investigating the reasons for the dramatically increased death rates across our province, and to leave the mentally ill to be treated as much as they possibly can be - in our broken health care system. I am shocked that we even need to have this conversation at this time in history. Haven’t Albertans and Canadians as a whole been traumatized enough over the last 4 years???

Gregory Chan

Medical Assistance in Dying is a morally reprehensible medical practice. MAiD (the terminology) evades an accurate description of this medical event - this is suicide delivered by a proxy - a physician or nurse practitioner.
Despair is suffering without meaning (Viktor Frankl). By allowing MAiD, we are effectively enabling society to abandon our patients, to stop creatively pursuing humanity, to stop finding meaning in the midst of disability and suffering.
MAiD unequally offers suicide only to select Canadians, based on government (legislative and legal) criteria. It is a human rights violation.
MAiD fractures the pre-suppositional approach to medical care - to enable patients to live well, to do no harm. Who should be offered suicide prevention, and who should be offered suicide assistance?
We should resolutely resist suicide in all of its forms.

Sherry Adams

I wish to voice my concern regarding the vulnerability of many patients who do not have supports needed to make healthy decisions and MAID is offered as an option to those who may feel like a burden! This is so wrong! I know of personal situations where persons were offered MAID and were not even terminally ill!!! They were in vulnerable situations and agreed to the offer! After asking her if that was what she really wanted, she felt it was against her conscience, however felt unworthy to stand up for herself and felt like she was a burden to her family! She denied MAID and lived another 2 years with her daughter- helping her with her son. I was shocked how quickly these decisions are “MAID”! I am even more concerned about the Mature Minor consent! I believe that is very dangerous and we must ensure the parents are the final authority with their children! No medical authority will have the heart of the child like the parent!


Thank you for allowing us to have input into this draft!
I am very concerned about these guidelines for the following reasons:

You have gone to great lengths to describe who can give consent for a minor to receive MAID, but then you state that “A regulated member who has reasonable grounds to believe an informed consent decision by a legal guardian or substitute decision maker is not in the best interests of the patient must seek legal advice, such as from the Canadian Medical Protective Association, or advice from the College”. All of a sudden somebody who doesn't even know the child has the power to make the decision of what is best for the child. Who is it that really gets to decide?!? This is terrifying! What teenager hasn't suffered a season of depression because of puberty and changing hormones? They need encouragement and support by the people that love and know them most to get through a challenging season, so that they can go on to enjoy life, not a pro-MAID physician pushing death for them. Parents must have the prior right in the decision making process. The responsibility of the decision has to lie with the parent. Our children can't even go on a school field trip without parental consent, how much more must they have our consent on a life/death situation!

I personally believe in the sanctity of life and would prefer to see MAID shut down completely in our country, but at the very least give parents the final say in the matter! I see the standard of “Do no harm” being set aside and I am very concerned. I plead with you to please stop this culture of death that is escalating in our country! Stop forcing doctors to promote it against their wishes. We already have a serious shortage of physicians in our province; this is just going to push more of them to stop their practice because of their personal ethics, and that is the last thing we need. It is time to promote life and health, not death!

Dr Shirley van der Merwe, MBChB

Thank you to the others who have so eloquently expressed their concerns regarding the expansion of MAiD to include mental ill health. In particular, thank you to Drs Lisa Burback, Hamza Riaz, Shelia Wang, Darryl Rolfson and David Lounsbury for your excellent points. I have 2 further concerns to add to those already raised:
1. By allowing MAiD for mental conditions, how will we be able to convince suicidal patients not to kill themselves and that it is just their disease process "speaking" when on the other hand others with a similar condition are being offered and are accessing MAiD? I am afraid that we will see a rise in attempted and completed suicide outside MAiD as death becomes seen as the "solution" to mental distress. Don't we already have enough of a problem with suicide without aiding and abetting?
2. I fear that the ongoing normalization of MAiD for any condition will add to the rapid attrition of Physicians from the health care system that promotes death as part of "health care". Each time I am asked by a patient to cross my conscience and have to gently but firmly remind them that I am obligated to "first do no harm", I suffer moral injury (even if I am free to decline involvement respectfully). Moral injury adds to work place stressors that have left many of us burnt out and caused some of us to close practices or reduce hours. By opening MAiD to those whose only condition is mental ill health will greatly increase the number of patients requesting MAiD and add to the burdens we already shoulder as physicians. Once the door is open to MAiD for mental ill health, there will be not shutting it later!

Rachel Hislop-Hook, MEd

Dear CPSA,

I am medical student with a Master's in Counselling Psychology, I am very concerned by the idea of the medical profession to allow MAID to patients whose a sole condition is a mental illness.

In the counselling profession, we are trained to think about suicidal ideation or a desire to die in much different way. We don't think that the mental illness is a CAUSE for desire to die - instead we collaborate with the client to get the real driving factor for why they want to die - which is often relational or occupational. These are matters of purpose/meaning, social inclusion and relationship.

There could also be issues of untreated trauma (there often is) that impairs self-worth. We work on these things, and use a variety of other strategies that consider the client as a whole person. Once we do so successfully, the suicidal desire takes care of itself.

I think we need to be very cautious when it comes to thinking about mental illness as a 'cause' for wanting to die. I think instead as medical professionals we need to borrow from the expertise of counselling to get to the bottom of why someone wants to die. A purely 'medical model' doesn't work when we are taking about issues of purpose, meaning, occupational opportunities, social inclusion, trauma and relationships.

At the very least, I think all patients who are considering MAiD should be provided with at least 6 sessions of counselling using a model like CAMS-Care (the gold standard for suicide prevention) which gets to the bottom of why a patient wants to die and works to treat their actual drivers in order to create a life the patient thinks is worth living (which can be possible even if the mental illness itself doesn't resolve).

We need to remember the basics of what medicine is here for: we are here to promote restoration and health first. This still needs to be the primary goal. We also need to not lose sight of the fact that we are treating human beings, not only mental illnesses.

Diane Severin

I cannot agree with MAID for any person. To expand the criteria to the mentally ill is pseudo compassion. Having lived experience with mental illness in my family members, I recognize the effect the illness has on their decision making which is vastly different than what they would do when well.

As a practicing oncologist, our patients complete a screening for distress form which asks them about suicidal ideation. If they identify thoughts of ending their life, we treat this as an emergency and obtain immediate psychological/psychiatric assistance for them.

What are we to do when the criteria are expanded? As a physician I would always try to get them the help they need but it seems ironic that one of the available options would be to see the MAID team.

Dr Deborah Andrew

I appreciate that you have sought our feedback regarding the important issues of the inclusion of mental health in MAID and the potential impact of changes to the Conscientious Objection Standards.
I am pleased to see that the phrase “effective referral” has already been removed from the Draft “Standard of Practice on Conscientious Objection”. As clearly outlined in many of the responses already posted, it is a travesty to compel physicians or any healthcare provider to take actions that are against their ethics and morals around upholding life.
It is of great concern to me that the Federal Government has taken measures through Bill C-39 which appear to side-step taking responsibility for improving resources and care for the increasing proportion of our population with mental health issues.
A Bill such as C-39 which makes assisted suicide available for mental health issues has never been considered a part of ethical medical care in Canada.
The size of the “mental health problem” is significant and it is time to address some of the contributors to this problem. These include addiction, isolation, hopelessness, family breakdown and difficulties in surviving day to day. This will require creativity and considerable human and financial input.
Offering assisted suicide to this fragile and vulnerable population is an abdication of our duty of care. What about supporting and helping them through their difficult times? What about allocating adequate funding and “effective resources”?
Those that have succeeded in coming through a time of suffering and depression often describe gaining more wisdom and personal growth from the experience and have more to offer humanity as a result of navigating that stretch of painful life experience. Are we to throw away all that human potential?
The elements of society that are pushing for this change in orientation of how we are supposed to serve our patients is, in my view, promoting an agenda cloaked in slick words and a “nice narrative” that will attempt to drag us all down a steep and slippery slope of loss of respect for the value of human life.
This plan is tainted with moral rot and is nothing short of a disgrace to our profession. What is next?
I believe that we in Alberta need to send a clear message to the Federal Government of Canada that we strongly reject the inclusion of mental health issues as a qualifying condition for MAID as outlined in Bill C-39. We need to fund Life, not Death.

John McDermott

College of Physicians and Surgeons of Alberta
Re Consultation 028

Dear colleges,

I would like to express concern about the upcoming modification of the Medical Assistance in Dying, Conscientious objection and Informed consent standards of care.

Following the Supreme court of Canada Carter decision of 2015, legislation was enacted to permit the provision of death inducing treatment to those with a grave and irremediable condition in whom death was reasonably foreseen. Although arguably euthanasia or physician assisted suicide, this treatment was labeled with the euphemism “MAiD”. This “treatment” went beyond the previously accepted approaches of palliative care and cessation of active intervention. Although many perceived some level of discomfort, others perceived ethical tolerability of “MAiD” as it was reserved to those patients who would inevitably die, sparing a long and drawn-out illness and a potentially violent demise at their own hand.

Euthanasia has of course been contemplated by physicians for millennia; even Hippocrates is said to have objected. In 2015, many already expressed concern about the “slippery slope” in Canadian law. As correctly predicted, over the past 9 years, “MAiD” has been expanded to include those patients who are not reasonably predicted to die and most recently those whose only illness is psychiatric. This has further been accompanied by mandates to refer, proposals to mandate participation in “MAiD”, proposals to prohibit belief-based care, loss of funding to institutions unwilling to participate in “MAiD” and likely rejection of medical school candidates too squeamish to participate. It is not unreasonable to predict that future court decisions may further expand eligibility and mandate physician participation to those providing advanced consent, consent by proxy (family members, guardians and curators), criminals and oppressors.

Issues surround trust of practitioners if of significant importance to patients. The expansion of availability of “MAiD” creates a perception among vulnerable patients uninterested in death that a physician may propose or enact euthanasia. Especially among patients with complex conditions, potentially with serious ailments, potentially with anxious heirs, muddling along in a slow, inefficient overburdened heath care system, the thought that it might be easier to let one of those kind doctors kill them should not be discounted.

Given the expansion of criteria for inclusion goes beyond the initial 2015 requirement of a grave, irremediable condition where death may be foreseen, and rather encompasses a large group of medical and social conditions, the term “Medical Assistance in Dying” should be reserved ONLY for those patients eligible to receive euthanizing treatment as per the original Carter 2015 decision. In all other more expansive cases where death is not reasonably predicted, the “MAiD” term should be retracted and correctly termed “Euthanasia care”. Similarly, the potential for future application of “MAiD” to prisoners should correctly be termed “Execution”, while the application to oppressors should correctly be termed “Murder”. This would apply to the CPSA standard of practice “Medical Assistance in Dying (MAID)” addressed in consultation 28.

As professionals in the delivery of health care, many would argue that medical staff should not participate in “MAiD” and euthanasia. Many have argued against euthanasia based on secular arguments, devaluation of human life, slippery slope, palliative care can relieve pain and loss of trust that physicians will heal. Arguments against euthanasia are numerous and need not be repeated in this forum.

A small, vocal minority of physicians do, however, continue to provide euthanasia as part of a gamut of medical services, presumably in a manner compatible with their moral and conscious beliefs, on the legitimate basis of wishing to alleviate suffering. Indeed, providing euthanasia, regardless of one’s beliefs surround this “treatment” does remain a legally recognized intervention in Canada. As a means of balancing the desire and ethical perspectives of those performing euthanasia with the conscientious objection for those who do not, the default expectation of a patient should be that the physician will heal rather than kill. In such manner, a patient will have full confidence that their physician will act to promote health and care while omitting “MAiD” and euthanasia from their scope of practice. Care provided by legitimate healers does include minimally controversial palliation and withdrawal of futile interventions at the end of life.

Rather than creating a conscientious objection standard, the CPSA may choose to encompass the euthanasia performing practitioners into the “Medical Assistance in Dying” standard. A reasonable inclusive step to promote trust among patients would be the establishment of a registry of physicians who are willing and interested in performing “MAiD” and euthanasia services. This registry could be provided on the CPSA website (or in writing), potentially with quantitative data including the number of patients successfully treated with “MAiD” for each euthanasia performing practitioner. As the provision of “MAiD” and euthanasia is promoted as being free of stigma and bias, indeed it is a well-recognized and compassionate treatment in Canada, one would expect that practitioners in this field would welcome insightful statistics. As the legal landscape evolves, those serving as euthanasia providing practitioners may benefit from additional training and CPSA provided course curriculum. This step would serve patient safety, as euthanasia performing practitioners would be expected to navigate the complex issues of informed, free, unbiased consent in accordance with the “Informed Consent” standard as applied to “MAiD”.

Similar to patients seeking a family physician, a patient seeking euthanasia services would be able to look up a euthanasia providing practitioner on the CPSA website, ideally in a local community, in order to undergo the treatment in a safe and expedited manner with full confidence that the practitioner is well trained, highly experienced and abreast of the legalities. Potentially in due time, euthanasia provision will be recognized as a distinct and exclusive act, carried out only by experts in the field.

I do wish to clearly express that I have not and will not engage in the provision of euthanasia services. Thank you for providing a forum to discuss this important issue.

Yours truly,

Dr John McDermott, MD, FRCPC

Luke Savage

MAiD is not the answer to mental health. It’s not the answer to suffering. And it is not something physicians (or nurses, or anyone in the healing professions) should be doing. In regards to mental health and a request for death, how do we determine who might get suicide prevention, and who would get suicide assistance? 8-1-1 is the number for both - how does the operator determine which pathway to move someone down? If a suicidal patient is brought to the emergency department, how do we determine if we call the psychiatrist or the MAiD team? Many patients with chronic mental health struggles know how to play the system, to say the right words to get what they want, even when their sense of reality is altered and their insight is poor. Allowing MAiD for mental health is a minefield for wrongful death.

Most physicians did not take the Hippocratic Oath. And yet most Albertans believe their doctors took that oath to do no harm, and to “neither give a deadly drug when asked for it, nor to make a suggestion to that effect.” Most Albertans would be shocked to know their physician did not take the Oath nor stands by it’s principles. Providing MAiD goes against the Hippocratic Oath and causes multiple negative ripple effects: it undermines the trust patients give to their physicians, it suggests that ending a patient’s life is an acceptable way to solve trials and tribulations, it puts vulnerable patients at risk as some lives are seen as not worth living, it removes innovation in medicine as it is easier and cheaper to facilitate death than to support living and find new solutions for suffering.

Modern medicine developed codes of ethics for a reason - to prevent a repeat of the medical atrocities of the early-mid 20th century - many of which were legal under the governments of the time. Just because a government changes a law does not mean medicine should change the standards or codes of ethics to accommodate that law. In fact, it is quite the opposite, particularly when it involves purposefully ending the life of patients. Our standards/codes of ethics do no good if they change at every whim of the government. Who knows what they might require next? As a teaching from 2000 years ago says, “you can’t use legal cover to mask a moral failure.”

Tony Peters

People will naturally die when they die, and we don't need others to "help" them die. Aren't we trying to prevent suicide? Isn't suicide viewed as a negative thing? Why are we helping them commit a terrible sin on their own life? Their own murder? I think MAID in all circumstances is bad, especially on minors without consent, and especially for mental health issues (are the affected people even capable of making their decision? Are those making those decisions for them sending their souls into eternal life when God didn't say it was time?

Ron Voss

These guidelines support the advancement of a growing culture of death in Canada. Whatever happened to the medical ethical standard of the Hippocratic Oath, to do no harm?
We need to have and defend doctors and nurses that respect parents, acknowledging that no one loves and cares for that child more, not even ‘caring’ professionals. Opinions do vary, and in the end, the responsibility for decisions need to lie with the parent(s). However these guidelines with respect to Advice to the Profession Re: Informed Consent for Minors essentially take that responsibility away from parents and transfers it to the state and the sacrosanct medical opinion of physicians and nurse practitioners. One word, this is evil. Dr. Mengele, “The Angel of Death” would be proud.

Jeanette Van de Bruinhorst

Do not expand MAID to include mentally vulnerable people. They are at an extremely vulnerable time in life, when they often do not see a way to continue, whereas if they would receive counseling, then they can learn how to work through their difficulties.

Satchi Gold

I am absolutely opposed to both mature minor and mentally ill patients being able to “consent” to self-euthanasia.
This is a violation of the Canadian Bill of Rights which enshrines the morality and values of the human family in society.
It is also a violation of medical ethic of “First Do No Harm!”

Suzanne Richard

I have watched many close people in my life suffer greatly before death. Those people received appropriate medical attention and care. They had access to shelter, food, friends, and family to support and help them. The ability to make a decision to receive MAID under those conditions, is fathomable. Our child, who in hindsight, has suffered with mental health since kindergarten has NOT received the appropriate care and/or support from ANY system in place. In fact, the program for family and friends to learn and assist in appropriate support and care of those suffering with mental health was canceled! Until access to full support and care can be appropriate, provided, and met in a fair and equitable manner, the expansion of MAID should not proceed or even be discussed for those suffering with mental illness!!!! The discussion should start with being appropriate! Providing access to MAID when one’s prefrontal cortex is NOT fully developed and being a large contributor to the ability to make decisions and manage stress is NOT fair or reasonable and definitely not appropriate! The full development of the prefrontal cortex generally happens between the ages of mid to late twenties, is individualized, and must be intact when these decisions are being made and regulated. Otherwise MAID is a CRUEL option that undervalues life and those who live it and have provided it! Accessibility to assistance and support without causing financial hardship is another discussion that should happen prior to the expansion of MAID. Our child is 27 now and has worked extremely hard to exist and is doing much better than ever before! For all kinds of reasons, she finally is receiving assistance that isn’t causing huge hardships. She is well on her way to being a contributing member of society and this has made a significant and positive difference to her existence. As she puts it … mom, they don’t want to help us, they just want us to kill ourselves!

Annette Brunet-Messerschmidt

I emphatically say “No” - do not expand the MAID Program to include adults with mental health illness/issues period, nor a further expansion to minors. The potential expansion of MAID to include “mature minors” is immoral and such a category or definition should not exist.

Carolyn Teyda


Carol Penner

I am disappointed, shocked and surprised that this is even an issue that is being questioned. In the country of Canada, we deem someone 21 years old to be responsible to rent a car. We deem someone responsible to rent a hotel room at 18. We deem someone responsible to babysit our children at age 12. Yet, we are questioning whether it is all right for someone younger than that to make a decision on their own life and health choices, and only by the advice of a complete stranger in the medical profession. It is the law to wear a helmet while pedaling your bicycle or driving a motorcycle. It is the law to wear a seat belt while driving a vehicle. It is against the law to eat/drink, fix your hair or be on a cell phone while operating a vehicle because that is distracted driving. These are everyday activities that our country has made laws on for the safety of our lives. For our own personal protection and for the protection of others. How can we then even possibly consider a law to end a life, especially allowing a minor/Child to make that decision? Absolutely not!

Amy verbitsky

The MAID program should not be expanded to those with mental illness or mature minors.

Evelyn Neame

I am strongly against extending MAID for persons whose sole underlying condition is a mental illness.

It takes over three months to see a health professional for mental health issues, which is longer than the timeframes for MAID. This means death becomes the first choice for those suffering from mental illness, and recovery is no longer an option. Other countries that have extended MAID to cover mental illness have included strict guidelines that require every possible form of treatment to have been tried first, and provide MAID only as a last resort. Alberta does not have these requirements, and that is unconscionable. Legislation has to make health and healing a priority, and both patients and medical staff need to be held accountable to standards which support wellbeing.

In Alberta, effective timely help for mental illness is not yet a reality and because of that, MAID should not be an option either. I know that death can be preferable to navigating a difficult system while depressed, anxious or financially stressed. As it stands, the proposed change in legislation will be the worst possible solution for both the health care system and the patient: there will be no motivation to provide the resources needed to deal with mental illness, and healing will not be an option for patients.

Extended timeframes and extensive guidelines need to be implemented to prevent widespread abuse of this next phase of MAID.

Rena Richards

MAID is helping the Government to save money as they are unable to afford healthcare for the mentally ill and Babyboomer generation that are now aging. This is sickening and inhumane.

Cameron Powles

I don’t support expansion of MAID for Mature Minors. Children are always the most vulnerable. It’s our job as parents/ adults to protect and nurture. The term “Mature Minor” doesn’t even make sense. Adolescents are not fully mature in many cases till they are in their 20’s. Insurance companies know this and charge accordingly.
Expansion of MAID for this demographic would be a crime.

Ryan Loewen

I do not agree with these changes. Mental illness should NOT be added to the list of approved MAID acceptances. Life is precious and valuable and should not be thrown away because someone is mentally not well. When people go through tough times in their lives, they don’t need people helping them give up, they need people helping them get better. Often times people become stronger and able to cope better and help others going through similar things if they have someone helping them through those times, and they do not give up.

Neither do I believe or would ever want my doctor or any of my friends who are doctors to be forced to carry this out or prescribe this for another human being. I wholeheartedly do not agree that doctors should be forced to carry this out if they also morally do not agree with it.

Helena Klassen

Please do not change the conditions in MAID to include more eligible individuals.
Suicide should not be normalized or made easy to access.

Life is a precious gift and our time here is but a vapour…..

Alison Knoepfli

MAID should never be offered to those with mental illness or children. Period!
I have worked in psychiatry for 30 years. I have seem people who are right out of their minds screaming but with the right treatment brought back to sanity. Preserve the sanctity of life.