Reimagining MAiD for psychiatric illness: Ethical dilemmas among Veterans, clinical realities, and the road ahead.

Introduction: The expansion of medical assistance in dying (MAiD) in Canada to include, as of Mar. 17, 2027, mental illness as a sole underlying medical condition (MI-SUMC) raises significant clinical, legal, and ethical concerns, particularly for Veterans, who are disproportionately affected by difficult-to-treat psychiatric conditions. Structural vulnerabilities, including poverty, discrimination, gender-based disparities, and poor access to care, compound psychiatric suffering and increase the risk of premature death among marginalized groups. Methods: The authors conducted a comprehensive review of clinical, legal, and ethical literature, including expert reports, case law, and systematic reviews. Key areas of analysis include terminology regarding difficult-to-treat conditions, limitations of current capacity assessments, structural vulnerability, and ethical tensions between suicide prevention and MAiD for MI-SUMC. Results: There is no consistent definition of difficult-to-treat conditions, with over 150 existing for major depressive disorder alone. Prognoses remain highly variable, weakening claims of irremediability. Current capacity assessments often overlook trauma, emotional states, and systemic barriers, introducing bias. Suicidality, a common symptom of psychiatric illness, complicates distinctions between autonomous MAiD requests and crisis responses. Last, evidence from jurisdictions like Belgium and the Netherlands demonstrates that structurally marginalized individuals are over-represented in psychiatric MAiD, raising concerns of systemic coercion. Discussion: Given the unresolved uncertainties around irremediability, suicidality, and access to care, a precautionary approach is warranted. Without equitable access to advanced, neuroscientifically informed treatments, some may request MAiD because of lack of alternatives. Safeguards such as longitudinal monitoring, inter-blinded assessments, and expanded access to care are essential to protect vulnerable groups, especially Veterans.