Medical-Assistance in Dying for Psychiatric Patients with Substance Use Disorder Requires Protective Public Policy

Abstract: Canada expands medical-assistance in dying (MAiD) to patients suffering exclusively from mental illness in March 2027. While Canadian policies for psychiatric MAiD have identified several mental illnesses eligible under these provisions (e.g., depression, personality disorders, PTSD), no consensus exists on whether substance use disorders (SUDs) or psychiatric patients with comorbid SUD are eligible, warranting immediate consideration. Several ethical issues arise in permitting MAiD under these circumstances. First, withdrawal, residual intoxication/effects, neurobiological alterations, cognitive impairments, compulsive behaviours, emotional dysregulation, and other intersecting debilities can lead to reduced decision-making capacity for persons with SUDs regarding treatment and end-of-life care. Second, fractured social connections with family/friends and social isolation from SUD can worsen both the primary psychiatric illness (e.g., depression) and SUD, and SUDs often exacerbate symptoms of other psychiatric illnesses. Finally, moral distress can arise in both the clinicians facilitating MAiD and the patient’s family members, where SUDs can be remediable and SUD remission can significantly improve symptoms of the psychiatric illness(es) leading them to seek MAiD in the first place. Objections that such an approach violates patient autonomy, perpetuates suffering, and contributes to social/legal stigma are addressed, and the overarching position that MAiD for psychiatric patients with concurrent SUD raises significant bioethical concern is maintained.

Keywords: Medical-Assistance in Dying for Mental Illness, Substance Use Disorder, Health Policy