This article contains references to eating disorders and death.
Lisa Pauli wants to die.
The 47-year-old has wrestled with the eating disorder anorexia for decades; she says she has had a warped relationship with her body since she was eight.
These days, Pauli says, she weighs 41 kg and may go days without eating solid food. She says she is too weak to carry groceries home without stopping for breaks.
"Every day is hell," she says. "I'm so tired. I'm done. I've tried everything. I feel like I've lived my life."
Pauli cannot legally get medical help to die - yet.
Canada's new assisted death criteria
An expansion of the criteria for medically assisted death that comes into force in March 2024 will allow Canadians like Pauli, whose sole underlying condition is mental illness, to choose medically assisted death.
Canada legalised assisted death in 2016 for people with terminal illnesses and expanded it in 2021 to people with incurable, but not terminal, conditions. The legal changes were precipitated by court rulings that struck down prohibitions on helping people to die.
The new mental health provision will make Canada one of the most expansive countries in the world when it comes to medical assistance in dying (MAID), according to an expert panel report to Canada's parliament.
Proponents of assisted death - which is still a novel concept in many parts of the world - say it is an issue of personal autonomy.
But six disability rights and religious advocates said that the pace of the planned changes to the assisted death framework in Canada brings additional risks of people opting for MAID because they are unable to access social services - the lack of which could exacerbate their suffering.
Canada's justice minister David Lametti dismissed criticism that the country was moving too fast or opening up the system to abuse.
"We have gotten where we are through a number of very prudent steps," Lametti said.
"It's been a slow and careful evolution. And I'm proud of that."
In 2021, 10,064 people died through medically assisted death, about 3.3 per cent of deaths in Canada that year. That compared to 4.5 per cent in the Netherlands and 2.4 per cent in Belgium, where assisted dying has been legal since 2002, according to each country's official data.
More than 30,000 people have died with medical assistance in Canada since 2016.
'A last resort'
Pauli first raised the idea of assisted death with psychiatrist Justine Dembo in April 2021.
Dembo served on an expert panel on assisted death and mental illness that presented a report to Canada's parliament last year. She assesses people for MAID, although on that visit, Pauli was seeing her for body dysmorphic disorder.
Pauli has tried many treatments and been hospitalised twice but says she still thinks constantly about what she has eaten and will eat.
Dembo told Pauli she could be eligible for assisted death once Canada's law changes.
"She's undergone very high-quality treatments, and they just have not made an impact," she said.
When Dembo assesses people for MAID, she said, she treats it as "a last resort" and tries to determine whether they have received all available medical and social supports.
Pauli says she plans to apply for MAID once she is eligible. When Pauli first broached the possibility of getting help dying, her mother, Mary Heatley, could not accept it.
"The wind knocked out of me … I just couldn't imagine her not being in this world," she said in an interview.
But Heatley talked to her daughter and realised what she was going through.
"She just could not foresee another 10, 20, whatever years of this, living with this eating disorder," she said.
"I say to myself, 'You have to try and remember. This is what she wanted. It's her life.' And I would just have to go on without her."
Challenges in assessing if a mental illness is irremediable
Some medical experts say mental illness alone should not be a criterion for assisted death. It can be difficult to determine whether a mental illness is truly irremediable, as the law requires, and to differentiate between pathological suicidality and a rational desire to die, says Sonu Gaind, chief psychiatrist at Toronto's Sunnybrook Health Sciences Centre.
"We don't even understand the biology of most mental illnesses," he said.
While the reported numbers of problematic assisted deaths in Canada are low, some opponents of assisted death in other jurisdictions are using the country's experience as a cautionary tale, three people involved in the debate in Britain said.
"Canada is being used primarily as an argument against us, not an argument in favour," Charles Falconer said, a British Labour peer supporting assisted death for people with a terminal illness in Britain, where it is not legal.
"It does in one sense [represent a slippery slope], doesn't it, because it started off with terminal illness and it's ended up with non-terminal illness and mental illness."
Readers seeking support for eating disorders and body image concerns can contact Butterfly Foundation on 1800 33 4673. More information is available at
Readers seeking support and information about suicide can contact 24 hours a day online and on 13 11 14. Other services include the on 1300 659 467, and (for people aged five to 25) on 1800 55 1800.
