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Rights + Justice

We’re Making a Terrible Mistake on MAID and Mental Illness

Why Canada’s rush to expand access to assisted death is a moral and medical failure.

Karandeep Sonu Gaind 15 Dec 2022The Conversation

Karandeep Sonu Gaind is a professor of psychiatry at the University of Toronto. This article originally appeared in the Conversation.

[Editor’s note: This story contains information about suicidal ideation and mental health crisis. It may be triggering to some readers.]

The federal government admitted Thursday it needs more time before expanding Canada’s controversial medical assistance in dying policy to include mentally ill people.

Although the government had recently announced its intention to proceed with expanding MAID for those with long-term mental health disorders by next March, Justice Minister David Lametti said he had heard from medical experts that the health-care system wasn’t prepared to deal with patients who want to end their lives for mental health reasons. He did not commit to a new deadline.

But the justice minister said Ottawa was only seeking to delay implementation of the MAID changes — it’s still clear the government remains intent on further expanding its legislation to include mentally ill people who are suicidal and could get better.

It’s one of many controversial elements of the proposed changes to the MAID legislation.*

When Canada embarked on this journey years ago, I cautioned about the importance of ensuring we “do the least harm” with our expanding laws. As physician chair of my hospital MAID team, I have seen the myths and realities that have fuelled our MAID expansion.

False autonomy and false compassion

As a society, we take comfort that MAID is provided for compassionate relief from suffering. Individually, MAID has been sold to Canadians as an autonomous choice, and framed as a right. When MAID was introduced in 2016, for those whose deaths were reasonably foreseeable, these principles may have been true. In contrast, our MAID expansion to non-dying disabled people has been misled by the fallacies of false autonomy and false compassion.

True autonomy requires true choice. For those of us fortunate enough to live lives with privilege, choosing “death with dignity” can be sold as an autonomous choice. Yet we have now had marginalized Canadians living in poverty be given state-supported suicide who have openly said they chose MAID not to avoid suffering from illness, but because society had failed to provide them a chance to live with dignity.

Most would be hard-pressed to argue it reflects true autonomy with a range of choices when the marginalized poor are enticed toward “painless” death to escape a painful life of poverty.

Canadians have rationalized that non-dying disabled people are being provided MAID in the name of compassion. However, it is not compassionate to provide death for one reason while pretending it is for another. We have reassured ourselves that MAID is for medical conditions that will not improve, or are irremediable. In the court cases that originally established MAID — which involved conditions like ALS and spinal stenosis — or for medical conditions like cancers, that can be true.

However, evidence shows it is impossible to predict that a mental illness will not improve in any individual. Yet expansion activists mistakenly believe they can make such predictions. Research tells us their chance of being right amounts to chance or less, with precision modelling showing only 47 per cent of “irremediability” predictions end up being correct.

Perhaps most tragically, the twin pillars of false autonomy and false compassion fuelling the expansion agenda have been propped up by the third myth of false safety.

Until now, expansion activists have reassured that “MAID is not suicide.” When provided to help avoid a painful death for those who are dying, we can distinguish MAID from suicide. Yet when expanded to those seeking death for mental illness, evidence shows MAID becomes indistinguishable from suicide. We cannot differentiate those seeking psychiatric euthanasia from suicidal individuals who resume fulfilling lives after being provided suicide prevention, rather than facilitated death.

All this sobering evidence is sadly borne out by our now common headlines of assisted suicide being provided to marginalized Canadians seeking escape from life suffering and poverty.

The government-appointed federal panel, chaired by an expansionist in favour of MAID for mental illness, was responsible for providing safeguards, standards and guidelines for how to implement MAID for mental illness. Instead, the panel recommended that no further legislative safeguards be required before providing death for mental illness, and did not provide any specific standards for the length, type or number of treatments that should be tried before providing MAID. Its report even suggested society had made an “ethical choice” that MAID should be provided even if suicide and MAID were the same.

Two members of the initial 12-member panel resigned, including a health-care ethicist and a mental health advocate with lived experience.

Suicide prevention

The whole issue of suicide prevention has been shockingly absent from many of these discussions, including those with key medical associations. In all of the consultations on Bill C-7, the Canadian Psychiatric Association (of which I am a former past president) inexplicably never once presented known evidence about suicide risks associated with mental illness.

While some organizations such as the Canadian Association for Suicide Prevention discussed the importance of preventing suicide, the CPA never raised this crucial topic.

With this vacuum of national leadership and evidence-based guidance, perhaps it is not surprising that our justice minister recently suggested that MAID “provides a more humane way for [people with mental illness] to make a decision” when “for physical reasons and possibly mental reasons, [they] can’t make that choice themselves to do it themselves.”

This remarkable statement, coming from the person entrusted with responsibly implementing Canada’s assisted dying laws, will keep me and many of my colleagues up at night.

The need to pause

I am not a conscientious objector. However it is clear to me that Canada’s planned expansion of MAID to mental illness is based on ignorance — if not outright disregard — of fundamental suicide prevention principles. It appears to ignore what drives the most marginalized people to consider death as an alternative to life suffering. Perhaps, though, it does not ignore the cost savings of providing MAID rather than treatment and community support for dignified living.

The Carter v. Canada and Truchon v. Canada court cases shaping MAID laws did not review or rule on MAID for mental illness, yet we are in the remarkable position of being less than three months away from providing facilitated suicide for the mentally ill without any standards, or any consideration of the role of suicide prevention.

Postponing the March 2023 expansion of euthanasia for mental illness is the only responsible course. Canadians and mental health organizations recognized this and called for it, with the Canadian Association for Suicide Prevention and over 200 individual psychiatrists so far signing a petition to this effect, and the academic chairs of the departments of psychiatry across Canada joining this call for delay.

To proceed with the planned changes would have been morally, medically and politically irresponsible. Moving forward, it will be important to ensure our future policies are evidence-based. Fortunately, the situation is not yet irremediable.*The Conversation

* Story updated at 8:42 p.m. on Dec. 15 to include further announcements from the federal government on the implementation of MAID.  [Tyee]

Read more: Health, Rights + Justice

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