Medical Assistance in Dying (MAiD)


Following the Carter v. Canada decision of Feb. 6, 2015, Canada passed federal legislation on Jun. 17, 2016 to allow Canadian adults to request medical assistance in dying (MAiD). The eligibility criteria, under Bill C-14, stated a person must:

  • be eligible for health services funded by the federal government, or a province or territory (or during the applicable minimum period of residence or waiting period for eligibility)
  • be at least 18 years old
  • have a grievous and irremediable medical condition
  • make a voluntary request for medical assistance in dying that is not the result of outside pressure or influence
  • give informed consent to receive medical assistance in dying

To be considered to have a grievous and irremediable medical condition, Bill C-14 required patients meet all the following criteria:

  • have a serious illness, disease or disability
  • be in an advanced state of decline that cannot be reversed
  • experience unbearable physical or mental suffering from an illness, disease, disability or state of decline that cannot be relieved under conditions that the patient considers to be acceptable
  • be at a point where natural death has become reasonably foreseeable

The eligibility criteria did not require a specific prognosis with regards to the time remaining to the patient.

Bill C-14 did not expressly exclude mental illness. It also did not include provisions on three issues: 1) advance directives, 2) mental disorder as a sole underlying condition, and 3) access for mature minors. These were deferred for further study, for which an independent panel was commissioned through the Council of Canadian Academies (CCA). On Dec. 12, 2018, the CCA released three final reports: one on each type of request

The CCA’s Expert Panel Working Group on MAiD Where a Mental Disorder Is the Sole Underlying Medical Condition did not arrive at a consensus on the best way forward in its final report. However, their report drew on the literature, international experience, and diverse perspectives to present key considerations, implications and potential safeguards.

On Sept. 11, 2019, the Superior Court of Quebec struck down the “reasonably foreseeable” provision in Canada’s assisted dying legislation (Truchon c. Procureur général du Canada) and gave the government until Mar. 11, 2020 to develop new legislation. The Truchon decision was not appealed by the Quebec or the Canadian governments. However, the federal government requested and received extensions to the original Mar. 11 deadline, passing bill C-7 on Mar. 17, 2021. The amended law:

  • Removed requirement for a person’s natural death to be reasonably foreseeable in order to be eligible for MAiD.
  • Introduced a two-track approach to procedural safeguards based on whether or not a person’s natural death is reasonably foreseeable: 1) existing safeguards will be maintained and certain ones will be eased for eligible persons whose death is reasonably foreseeable and 2) modified safeguards will be introduced for eligible persons whose death is not reasonably foreseeable.
  • Allowed the waiver of final consent for eligible persons whose natural death is reasonably foreseeable and who may lose capacity to consent before MAiD can be provided.
  • Expanded data collection and analysis through the federal monitoring regime to provide a more complete picture of MAiD in Canada.
  • Excluded eligibility for individuals suffering solely from mental illness for 24 months and required the Ministers of Justice and Health to initiate an expert review tasked with making recommendations within the next year on protocols, guidance and safeguards for MAID for persons suffering from mental illness.

The Expert Panel on MAiD and Mental Illness was formed in August 2021 to undertake the review required by bill C-7. On May 13, 2022, the panel delivered its final report, making 19 recommendations that, in its view, could be fulfilled without adding new legislative safeguards to the Criminal Code but rather by buttressing existing laws, standards and practices in healthcare.

In September 2022, Health Canada convened a task group to develop MAID practice standards in advance of March 2023 based on recommendations 2 through 13 of the final report of the Expert Panel on MAID and Mental Illness.

On Jan. 1, 2023, new federal MAID reporting requirements came into force. These regulations were amended to align with the changes to the Criminal Code arising from bill C-7. Further, a guidance document was created to support health care professionals in fulfilling their responsibilities under the amended regulations.

On Mar. 9, 2023 Canada passed legislation to extend by one year the temporary exclusion of eligibility for MAID on the sole basis of a mental illness. The new deadline of Mar. 17, 2024 was to provide more time for the dissemination and uptake of key resources, including MAID practice standards, a MAID education and training curriculum and to consider the recommendations of the Special Joint Committee on MAID’s final report.

Health Canada released the Model Practice Standard for MAID on March 27, 2023. Developed in response to the first recommendation in the report of the Expert Panel on MAID and Mental Illness, the model standard covers aspects of MAID practice relevant to MAID where a mental disorder is the sole underlying medical condition (MAID MD-SUMC) as well as content relevant to all requests for MAID, particularly track two requests where a person’s natural death is not reasonably foreseeable. A companion document to the standard, “Advice to the Profession,” provides additional guidance and clarification on specific clinical questions raised by the model standard.

A nationally accredited, bilingual MAID training program for physicians and nurse practitioners was released in Canada on Sep. 13, 2023. The Canadian MAiD Curriculum (CMC) was developed by the Canadian Association of MAID Assessors and Providers and is aimed at all clinicians, with or without MAID experience. It is comprised of seven modules, including one on MAID and mental disorders. The curriculum is free for clinicians (licensed physicians and nurse practitioners) until March 2026.

On Oct. 31, 2023, five months prior to the coming into force of eligibility of MAID MD-SUMC and as per recommendation 13 of its final report , the Special Joint Committee on MAID was reconstituted “to verify the degree of preparedness attained for a safe and adequate application of MAID (in MD-SUMC situations)”.

CPA’s Position on MAiD

Within Canadian psychiatry there are divergent opinions with respect to the provision of MAiD, as well as whether access to MAiD should be permitted solely on the basis of a mental disorder. There are compelling legal, clinical, ethical, moral and philosophical questions that make this issue particularly challenging. At this time, the CPA has not taken a position on whether MAiD should be available in situations where mental illness is the sole underlying medical condition.

On Mar. 13, 2020 CPA published a position statement that was written in the context of the current legislation, Bill C-14, and is in keeping with international human rights agreements to which Canada is a signatory (i.e., the UN Convention on the Rights of Persons with Disabilities).

The CPA position statement said that “patients with a psychiatric illness should not be discriminated against solely on the basis of their disability, and should have available the same options regarding MAiD as available to all patients” [emphasis added]. The statement did not say “patients with only a psychiatric illness,” nor did it take a position—either express or implied—that psychiatric illnesses are grievous and irremediable.

The Professional Standards and Practice Committee prepared the position statement at the Board’s request and CPA governance policy, which states that papers and statements are usually developed through committees or councils on subjects reflecting the scope of their mandate or as authorized and prioritized by the Executive Committee or the Board.

Consultation with Members

The CPA has engaged members on this issue since 2016, through surveys, a time-limited task force, and symposia at annual conferences. CPA gathered information about the range of opinion among psychiatrists through a 2020 survey, member town halls, and a call for written comments from our members. This member consultation was bolstered by feedback from members of the provincial psychiatric associations, as well as the psychiatry subspecialty academies of child and adolescent, geriatric, forensic, and consultation-liaison psychiatry.

This consultation work was led by a group co-chaired by the CPA’s Public Policy Committee and Professional Standards and Practice Committee. The working group, which is nationally-representative, includes psychiatrists with a cross-section of expertise such as provision of MAiD in Canada, epidemiology and/or research in MAiD, health-care policy regarding MAiD, and ethics. The working group also includes a member with lived experience of mental illness.

On Aug. 13, 2021, the working group released a discussion paper examining several aspects related to MAiD including decisional capacity, informed consent, and appropriate safeguards. To help inform policy-makers as they prepared for the end of the temporary exclusion of mental illness as the sole basis for a request for medical assistance in dying (MAiD), in November 2021 the CPA renewed its call for member and stakeholder feedback on the discussion paper, and prepared a report summarizing the comments and recommendations CPA received.

Recommendations to Government

The CPA has previously made submissions to the federal government or appeared before government committees regarding MAiD. CPA submitted a brief to the House of Commons Standing Committee on Justice and Human Rights on Nov. 12, 2020, as well as the Senate Standing Committee on Legal and Constitutional Affairs on Nov. 23, 2020 about the proposed bill C-7.

The CPA supports equality and dignity for persons with psychiatric disabilities. In the context of any proposed amendment to legislation related to MAiD the CPA strongly advocates for equitable access to clinical services as an essential safeguard to ensure that people do not request MAiD due to a lack of available treatments, supports or services. MAiD must uphold the rights of and protect all vulnerable Canadians without unduly stigmatizing and discriminating against those with mental disorders.

Assessing decisional capacity for consent to an irreversible and fatal medical procedure such as MAiD is very complex, especially when there is a concurrent mental illness and even more so when mental illness is the sole underlying condition. Psychiatrists have specialized training and expertise in the assessment, diagnosis and treatment of mental illnesses including the assessment of decisional capacity and the durability, stability, and coherence of a person’s expressed will and preferences. Psychiatrists are well-versed in taking into consideration any external constraints or internal psychopathology that may impact these issues.

CPA Collaboration on MAID Resources and Education

Through its MAID working group, the CPA provided feedback on the MAID practice standard prior to its release.

The CPA was part of the Canadian MAID Curriculum steering committee, which supported the development of a training curriculum for assessors and providers which is now available. CPA members were also part of the working groups that developed individual curriculum modules.

CPA regularly informed members about the development of the practice standards and their contents, as well as the curriculum. We continue to keep members abreast of and facilitate MAID training opportunities.

At its 2022 annual conference, CPA held a panel discussion where 140 delegates explored ethical considerations to guide MAID decisions, assessment of capacity and voluntariness, as well as suicide versus MAID. At its October 2023 conference, 350 annual conference delegates attended a plenary that discussed the need for a national MAID curriculum and outlined its development. In conjunction with the conference, CPA also hosted a facilitated session of the MAID and mental disorders curriculum module for CPA members.

The CPA’s peer-reviewed journal, The Canadian Journal of Psychiatry, has published several articles that seek to clarify aspects of MAID, including original research by van Veen and colleagues that establishes 13 consensus criteria for determining irremediability in the context of MAID in the Netherlands.