Put the Brakes on Allowing Medical Assistance in Dying for Those With Mental Illness
By Harvey Max Chochinov
It’s time to put the brakes on Medical Assistance in Dying (MAiD) in Canada for those whose sole underlying medical condition is mental illness.
The federal government has tasked the Special Joint Committee on Medical Assistance in Dying to determine if Canada is ready to extend MAiD eligibility, starting in March 2024, to patients with mental illness alone. Despite those convinced it is time, and safe, to launch what amounts to ‘psychiatric euthanasia,’ the Special Committee must pay attention to a murmur of protest that has grown to a roar: “Ottawa, we’ve got a problem.”
There are two main reasons to abort this mission. Current MAiD eligibility requires a person to have a grievous and irremediable medical condition. Unlike some cancers, and many neurodegenerative disorders, no mental disorder can be described as irremediable. To be sure, there are individuals whose mental affliction won’t improve, despite myriad treatments or psychosocial interventions. But there is currently no way to predict which patients won’t get better.
Studies of prognostic accuracy show psychiatrists are wrong half the time. I have cared for patients struggling with chronic suicidality; patients I worried might one day take their lives. I recall a woman with mind-numbing depression who teetered precariously between life and death. One day, after years of countless drug trials, hospitalizations, electroconvulsive therapy, and various psychosocial interventions, she arrived for her appointment — three weeks into starting a new antidepressant — with a grin on her face.
“The door is purple,” she declared. I told her the door had always been purple, to which she replied, “I know, but now I care.”
Before that moment, no one — not me, not her friends or family and not anyone on The Special Joint Committee on Medical Assistance in Dying, nor any MAiD assessor — could have predicted her recovery.
Intensive, unwavering, compassionate care and caring —not MAiD — offers the most effective way to address this kind of suffering.
The other reason not to launch psychiatric euthanasia is our inability to determine suicidality from those requesting MAiD whose sole underlying medical condition is mental illness. According to the Canadian Association for Suicide Prevention, someone not dying because of their condition, such as a mental disorder alone, seeking death is, by definition, suicidal.
Similarly, the first item listed by the American Association of Suicidology differentiating physician hastened death and suicide is the patient must be dying. That certainly does not characterize patients who are mentally ill.
Despite this, the Special Joint Committee is being told by some MAiD expansionists, “suicidality and having a reason to want to die are not at all the same.” We can say ‘six’ and ‘half-dozen’ are not the same as many times as we like. If we repeat it frequently, consistently and without equivocation, it might even sound convincing, but that doesn’t make it true.
Patients struggling with suicidality often have a reason to want to die, based on, for example, self-loathing, feeling a burden or becoming worn down pursuing care and support that could sustain them. In those instances, the line between MAiD and suicide simply vanishes.
Most proponents of psychiatric euthanasia are prepared to overlook all of this, claiming failure to expand MAiD to the mentally ill is discriminatory. Avoiding discrimination does not mean everyone is treated the same, but rather that everyone gets equal access to what they need to thrive.
Claiming a lethal injection for mentally ill patients is a respectful, compassionate, and necessary response to their suffering is akin to arguing the virtue of helping people to the balcony of a burning building so they might choose death rather than sorting out how to control or extinguish the fire.
Time and again, committee members have asked witnesses when Canada’s psychiatric euthanasia program can be launched. I would suggest they behave like NASA. When a potentially catastrophic problem is identified before blast-off, space engineers don’t set an arbitrary new launch date, no more so than Health Canada announces a random release date of a new drug discovered to have unacceptable side effects.
Members of the Special Joint Committee must listen and exercise reason, wisdom, and restraint in the face of fierce opposition.
“Ottawa, we have a problem.” The federal government would be well advised to scrap this mission. But if it insists on moving forward, the launch should proceed only when the problems are solved, and not a moment sooner.
Dr. Harvey Max Chochinov is a distinguished professor of psychiatry at the University of Manitoba, and author of Dignity in Care: The Human Side of Medicine, recently published by Oxford University Press.