Evidence is required before including mental illness in assisted death legislation

If the coronavirus pandemic teaches us anything, it is that science matters. However much spin is applied, personal opinions cannot replace facts reflecting evidence. Ironically, as a battle wages south of our border to let science guide social policy and protect healthy people from getting ill from coronavirus, a similar debate is occurring here to avoid exposing ill people to arbitrary deaths.

In December, the restriction that medical assistance in dying (MAID) be provided only when natural death is reasonably foreseeable will be removed. The importance of remaining safeguards is exponentially heightened to ensure we end the lives only of those whom society agrees MAID should be provided for. In Canada, MAID is meant as a compassionate option for ending suffering for those with a “grievous and irremediable” medical condition. Without safeguards, we may soon start providing MAID to those who do not have irremediable medical conditions and would have gotten better (and we will never know, since we will have taken their lives before they could improve).

This risk is particularly high for those suffering from mental illnesses. Although initial draft legislation would not allow MAID for sole mental illness, some advocates are citing concerns about discrimination and arguing to expand MAID to mental illnesses.

Mental illnesses can be grievous, and can lead to significant suffering. Even on rare occasions when individuals’ symptoms do not improve, addressing coexisting psychosocial stresses almost always reduces suffering. However, to honestly provide MAID for the purposes society accepts, it is not enough to know after the fact that, rarely, some individuals did not improve — we need to be able to predict, in advance, who will not improve in the future. And this is where our own homegrown science versus alternate facts debate comes in.

There are no standards for predicting irremediability in mental illnesses, nor is there evidence to show that this can be done. In reviewing the topic CAMH has stated “there is simply not enough evidence available in the mental health field at this time for clinicians to ascertain whether a particular individual has an irremediable mental illness.” Heightening concern, there is also evidence showing overlap between individuals seeking MAID for mental illness and suicidal individuals whom we traditionally try to help with suicide prevention efforts.

It is important to recognize this is different from “miracle cures” in other parts of medicine. For illnesses like cancer, ALS, spinal stenosis or others, we do understand the typical course of illness and can make reasonable predictions, miracle cures aside. For mental illnesses, that we do not even understand the underlying biology of, we lack the evidence to make such basic predictions.

Some advocates for expanding MAID believe irremediability can be identified in mental illnesses, despite the lack of standards or evidence. I have had colleagues who normally demand evidence for any intervention in medicine state they believe they can identify irremediability “because they know it when they see it”; yet they acknowledge having had many patients get better who they thought never would.

The Canadian Psychiatric Association (CPA) has released a position statement on MAID, without membership input or evidence, advocating that “patients with a psychiatric illness ... should have available the same options regarding MAID as available to all patients.” Yet CPA has since acknowledged that the statement did not consider “whether psychiatric conditions are irremediable and if so, how this should be assessed.” The CPA has faced criticism over its position, including in its own medical journal. Decrying the lack of evidence fuelling MAID policy, mood experts Drs. Schaffer and Sinyor write in the September Canadian Journal of Psychiatry that CPA’S position is an abdication of CPA’S responsibility, and that it is “absurd and even shameful” that those proposing expansion of MAID have not been held to the usual standards of medical science.

Those advocating for expanding MAID for mental illness are entitled to that opinion, however they should not be entitled to their own facts. It is wrong for them to distract from the real issue and claim, reflexively, that it is discriminatory to not allow MAID for mental illnesses. In Canada, MAID is supposed to be an option for those suffering with medical conditions we can assess as irremediable. In my opinion, it would be discriminatory to expose those suffering from mental illness to arbitrary deaths, based on arbitrary assessments of irremediability for which there are no standards. Science is based on evidence, and policy should be based on science, not slogans.