MAID for mental illness opens dangerous doors
‘Is our answer to make death easier for those we have failed?’
Last week the Canadian Senate voted to recommend a “sunset clause” on the exclusion of mental illness as a sole eligibility criterion for medical assistance in dying (MAID).
If ratified by the House of Commons, within 18 months people suffering solely from a mental illness will be able to request MAID. Some argue that prohibiting access to MAID for mental illness is unconstitutional and discriminatory. Unfortunately that claim is based on a superficial notion that anything being treated differently reflects undue discrimination. In reality, significant differences exist between illnesses that are mental in nature and those that are physical, such that removal of this prohibition would be more than merely discriminatory, it will be fatal for those who most need protection and care within a protective legal framework.
Most obviously, mental illnesses that are typically approved for MAID in permissive jurisdictions like the Benelux countries feature suicidality as a core diagnostic symptom of illness. No physical illness has suicidality as an integral symptom of illness. Bill C-14 and Bill C-7 recognize suicide as an important public health issue. Evidence shows significant overlap exists between those with suicidal wishes as symptoms of mental illness and those requesting MAID for mental illness; we cannot readily tell these groups apart. Evidence also shows that, unlike MAID for physical illnesses, more socially vulnerable people seek MAID for mental illness, and twice as many women as men receive MAID for mental illness.
Opening the doors to MAID for mental illness risks undermining suicide prevention strategies that protect patients vulnerable to suicidal death wishes. Whereas suicide prevention strategies involve restricting access to lethal means, permitting MAID solely for mental illness does exactly the opposite, and risks co-opting a mental health system intended to help prevent suicides into facilitating suicide for those whom our health and social systems have failed.
Equally concerning, we would be pretending MAID was being provided for irremediable medical conditions, which society has been led to believe MAID is for. For mental illnesses, unlike for physical illnesses, there are no evidence-based standards to determine “irremediability.” Physical illnesses such as advanced cancer or neurodegenerative disorders have much more predictable courses, and the underlying biology of mental illnesses is much less well understood. After years of study, expert groups like the Council of Canadian Academies, and the Centre for Addiction and Mental Health, have stated there is currently no evidence that irremediability can be predicted in mental illnesses.
If MAID for mental illness was permitted, some who are suicidal from mental illness symptoms will receive MAID, including those who would have recovered, with years of potential life remaining.
Recently the Association des médecins psychiatres du Québec (AMPQ) suggested a potential framework for allowing MAID for mental illness. Despite some good thought in the document, it strikingly suggests that “eligibility criteria are not only questions of fact but of value,” and that it is an “ethical question” for assessors to determine the certainty of eligibility for someone requesting MAID for mental illness. This statement is alarming given that this same document acknowledges that “the underlying pathophysiological processes involved in most mental disorders are unknown” and that “a person who has recourse to MAID could have regained the desire to live at some point in the future.” Public health policy that risks providing death to suicidal people, who could otherwise have recovered, should be based on available evidence and standards, not arbitrarily on individual value judgments of assessors.
The “sunset clause” proposed by the Senate simply creates an arbitrary timeline, it does not get around this fundamental lack of evidence, nor the lack of knowing whether it is even possible to predict irremediability in mental illness. A sunset clause cannot create non-existent evidence; just as coronavirus cannot be told an arbitrary time frame by which to disappear, evidence cannot be told an arbitrary time frame by which to appear.
We should remember the lived reality of Canadians. In any year, one in five Canadians suffers from mental illness, yet less than one in three who need it receive care. Is our answer to make death easier for those we have failed to give a chance to live better?
The highest international authority, the United Nations Office of the High Commissioner for Human Rights, has recognized these risks. Earlier this year the office released a powerful statement concluding that “under no circumstance should the law provide that it could be a well-reasoned decision for a person with a disabling condition who is not dying to terminate their life with the support of the state.” The question is, are our Canadian policy-makers listening?