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63 Med. Sci. & L. 3 (2023)

handle is hein.journals/mdsclw63 and id is 1 raw text is: Editorial Ethical considerations regarding mental disorder and medical assistance in dying (MAiD) in the prison population Introduction Medical Assistance in Dying (MAiD) has rapidly advanced in Canada in recent years including its use within prison popu- lations. In June 2016, the prohibition on physician-assisted suicide in Canada's criminal code was rescinded, and MAiD was enacted under Bill-C14. This allowed competent persons over the age of 18 with 'grievous and irremediable' medical conditions to be eligible for MAiD under the condi- tion that death was 'reasonably foreseeable' and that the request is made voluntarily. A 'grievous and irremediable' medical condition was defined as a serious and incurable illness, disease or disability that causes enduring and intoler- able physical or psychological suffering and cannot be relieved under conditions the person considers acceptable. In March 2021, further legislative revisions in Bill-C7 removed the prerequisite of a foreseeable death. This change initially excluded 'mental disorders as the sole underlying medical condition' (MDSUMC); however, mental disorders will qualify for MAiD from March 2023. Given that Section 86(1) of the Corrections and Condition Release Act obliges inmates the right to access 'essential healthcare' and that exist- ing policy deems MAiD a healthcare procedure, prisoners are entitled to MAiD services for non-terminal and terminal medical conditions that otherwise meet the legal thresholds. In 2021, 3.3% of all deaths in Canada were by MAiD, almost all by physician-delivered euthanasia which is the highest rate in the world.1 Corrections Services Canada pub- lished Guideline 800-9 to outline the procedure for MAiD requests specific to the intricacies of the incarcerated setting.2 Mental illness and suicide among prisoners Prisoners have a high prevalence of psychiatric conditions with approximately 14% of inmates having major mood disor- ders or psychosis and high comorbidities of substance use dis- order contributing to increased risk of suicidality.3 Suicide is the leading cause of unnatural deaths among federal prisoners in Canada accounting for 20% of all inmate deaths annually.4 When compared to the general population, this amounts to an elevated relative risk of suicide of 3-6 among male inmates and reaching as high as 56 among female inmates.5 Medicine, Science and the Law 2023, Vol. 63(1) 3-5 © The Author(s) 2022 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/00258024221146725 journals.sagepub.com/homems *SAGE Prison is recognized as an environment that can exacer- bate the severity of mental illness and suicidality, which raises concerns that incarceration creates intolerable condi- tions for some that may contribute to a request for MAiD. The expansion to include MDSUMC intensifies ongoing concerns regarding the poor transparency and limited data of MAiD within the correctional system.1 It is imperative that the ramifications of this eligibility expansion in the prison setting are carefully considered. The principle of 'Equivalence of Care' for prisoners The principle of 'equivalence of care' asserts prisoners the right to healthcare equivalent to the general population and is often used to support inmate access to MAiD.6 Unfortunately, incar- ceration often exacerbates hopelessness and distress among inmates while simultaneously providing barriers to receiving psychiatric care. Furthermore, opportunities for community- based interventions to assist someone with a serious mental illness, such as amendment in living circumstances, activities or the relational milieu, are often greatly compromised for prison inmates due to the nature of the institutional regime. Thus, neither the milieu that can exacerbate mental conditions nor access to treatment and rehabilitation is equivalent to those in the community, and thus a mental disorder that may be 'remediable' in the community may not be so in custody. Psychiatric conditions and 'Irremediability' To qualify for MAiD, the health condition must be both grievous and irremediable, where efforts to relieve suffering are deemed inadequate by the patient, with no acceptable treatment options remaining. With our current state of psy- chiatric knowledge, we have no reliable way of predicting the time course of an individual's mental illness. In the Netherlands, where MDSUMC is permitted, it was found that 11% of those who completed MAiD for mental illness had a dispute as to whether the underlying mental disorder was truly 'irremediable'.7 Additionally, patients commonly received new diagnoses during their MAiD