Opinion: We may never be ready for MAID in cases of mental illness

My decision to join the Special Joint Committee on Medical Assistance in Dying was not taken lightly. Here’s why we decided to press pause.

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With the deadline looming to extend eligibility for medical assistance in dying to those whose sole underlying condition is severe mental illness (known as MD-SUMC), last fall the government struck anew the Special Joint Committee on Medical Assistance in Dying to study health system readiness for such an extension. To clarify, the committee’s mandate did not include looking at advance requests in cases of neurocognitive disorders like Alzheimer’s.

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My decision to join the committee was not taken lightly. I am not a psychiatrist nor a psychologist. However, in a democracy not all is left to the experts. While it is vital in the realm of policy and law that experts be properly consulted and the authority of experience and knowledge afforded its due, in the final analysis the people, through their elected representatives, set legal parameters on crucial matters of public interest. This has been the case with MAID since 2016.

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The central, but not the only, question in MD-SUMC is irremediability; that is, whether there is a possibility a person with severe mental illness can be relieved of their suffering — a suffering that can be no less severe than physical suffering.

Currently, to be deemed eligible for MAID, a person’s illness must be grievous and irremediable. Irremediability is not, however, defined solely in absolute medical terms. In MAID law, “irremediable” means the condition is incurable and the person is in an advanced state of irreversible decline, and is enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions they consider acceptable. It is the responsibility of the physicians or nurse practitioners assessing the request to ensure the legal criteria have been met.

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In the case of mental illness, an accurate prognosis of incurability is more elusive. By some expert accounts, the degree of accuracy in predicting incurability is less than 50 per cent. A determination of irremediability is therefore more subjective, resting on a shared understanding of the situation between patient and assessor.

In formulating their opinion of irremediability, the assessor must necessarily rely more heavily on a retrospective view; that is, on an assessment of a patient’s past treatments and whether they have exhausted all reasonable treatment possibilities in seeking to be relieved of their suffering.

The problem is that the MAID assessor likely will not have been involved in those treatments. This makes it more difficult to ascertain the quality of those treatments, especially in a health system labouring for years under severe stress.

As Dr. Sonu Gaind, chief of psychiatry at Toronto’s Sunnybrook Hospital, suggested to committee members, “Try those mental gymnastics on your constituents. Convince them it was OK that their loved ones with mental illness got MAID, not because of a clinical assessment based in medicine or science, but because of the ethics of the particular assessor.”

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Expert witness testimony also highlighted the difficulty of separating suicidal ideation from an unfettered request for MD-SUMC. Suicide attempts are not always rash and impulsive, the product of a panicked state. This in some ways is a stereotype.

What’s more, psychiatric disorders are complex. In the Netherlands, where MD-SUMC is legal, over 70 per cent of psychiatric patients who died this way had more than one psychiatric disorder. While the Netherlands requires an assessment of eligibility for MD-SUMC by an independent psychiatrist, in Canada this would not be the case.

Further, in this country a patient would be eligible for MD-SUMC even if they refused treatment. A psychiatric patient may refuse additional treatment owing to treatment fatigue. According to research referenced in the Canadian Medical Association Journal, while treatment fatigue has been studied in the context of HIV and Type 1 diabetes, it has not yet received attention in psychiatry. A better understanding of treatment fatigue could lead to alternatives to MD-SUMC like palliative or recovery-oriented treatments.

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Another issue raised by expert witnesses was the potential role of psychosocial factors like poverty and isolation in motivating requests for MD-SUMC. To again quote Dr. Gaind, “Suffering is cumulative, and life suffering unfortunately fuels much of the suffering of those with mental illness, even more so for marginalized populations.”

We know that systemic racism is present in the health care system — one need only ask the family of Joyce Echaquan. Indigenous representatives have expressed serious reservations about expanding MAID to include those with severe mental illness. Professor Kaiser Archibald of Dalhousie University reminded the committee that in 2021 “distinguished Indigenous signatories wrote to Parliament” that this population, which is “vulnerable to discrimination and coercion,” has not been adequately consulted.

Among psychosocial factors, gender-based marginalization could influence requests for MD-SUMC. In countries that allow the practice, the ratio of women to men who receive MD-SUMC is two to one.

The Senate has appeared resolute on extending MAID to cases where the sole underlying condition is severe mental illness. As a legislator, I respect and value the Senate. Senators bring more than just sober second thought to the parliamentary process. They bring experience and expertise in a variety of fields crucial to shaping good public policy. But the fact remains that senators are not elected.

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After listening to expert testimony, the committee concluded that Canada is not ready to proceed with MAID in cases of mental illness. We cannot ascertain the irremediability of a psychiatric illness with any acceptable degree of confidence. We cannot sufficiently distinguish an unfettered request for MD-SUMC from suicidal ideation. We would not require the involvement of a psychiatrist in the assessment of eligibility for MD-SUMC nor that a person have reasonably exhausted available treatments. We are not able to truly separate out psychosocial factors in motivating a request for MD-SUMC. And we have not properly consulted racialized communities to take account of their concerns and fears.

We are not ready and may never be.

Francis Scarpaleggia is the member of Parliament for the West Island riding of Lac-Saint-Louis

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