Evidence lacking to support inclusion of mental illness in assisted-dying framework

The U.S. Senate recently acquitted the former president despite a preponderance of evidence implicating him in the incitement of the Capitol Hill riot on Jan. 6 that left five dead, highlighting the victory of expediency over evidence. In similar fashion, our own Senate has equally conveniently overlooked all existing evidence, setting us on track to sentence far more people to arbitrary premature deaths. The Canadian Senate recommended amendments to Bill C-7 that significantly reduce safeguards protecting vulnerable people from medical assistance in dying. The Senate also recommended a “sunset clause” on C-7’s exclusion of mental illness as a sole criterion for MAID, meaning that, in 18 months MAID, would be provided to those suffering solely from a mental illness. Notwithstanding diverse opinions on this question, the real debate is not about whether assisted death should be offered for mental illness. The real question is whether mental illnesses could possibly qualify for MAID under conditions the Canadian public has been assured it’s being provided for. On this question, there is no legitimate debate. The fundamental underpinning of most requests is supposed to be the presence of “a grievous and irremediable medical condition.” The blunt and indisputable reality is that, unlike for much more predictable medical conditions, it remains impossible to predict whether the situation is irremediable. The Centre for Addiction and Mental Health has concluded “there is simply not enough evidence available in the mental health field … to ascertain whether a particular individual has an irremediable mental illness.” After 15 months of studying worldwide evidence, the Council of Canadian Academies found the same thing, and both the American Psychiatric Association (APA) and Royal Australian and New Zealand College of Psychiatrists (RANZCP) have concluded evidence does not support providing MAID for sole mental illness. Expansion advocates propose mitigating this reality with “safeguards.” This ignores the notion that irremediability is itself the primary safeguard into the MAID framework, and bypassing it renders all other supposed “safeguards” meaningless. Without being able to predict irremediability, it’s apparent that MAID would be provided to some people who would have gotten better—there is no safeguard against that. Suggesting otherwise is akin to a society declining to have the death penalty over concerns of potentially executing the innocent, then implementing the death penalty anyway with false “safeguards” to reassure the public while wrongly accused innocents are executed. Regrettably, while the APA and RANZCP have provided meaningful evidence-based guidance in their societies’ debates on MAID and mental illness, our psychiatric associations have not. After not consulting members for years, in 2020, the Canadian Psychiatric Association released its position statement that “patients with a psychiatric illness … should have available the same options regarding MAID as available to all patients.” At the same time, it acknowledged that the statement wasn’t intended to “examine whether psychiatric conditions are irremediable and if so, how this should be assessed.” In recent Senate hearings, the president of the Quebec Psychiatric Association responded to concerns about evidence and the scientific method by saying “this is not a data-driven question, this is an ethical question.” It was a sentiment reflected in a document purportedly offering guidance on developing a MAID framework for mental illness. Medical bodies should provide evidence-based guidance within the wheelhouse of their expertise, not sidestep evidence to present other value based opinions. Other evidence-based cautions highlight the risks of providing access to easy death to suicidal, vulnerable, and marginalized populations who are not dying but suffering from psychosocial life stress. These concerns simply serve as icing on the cake to the indisputable evidence-based reality that MAID for mental illness cannot be provided for a predictably irremediable condition. And the Senate’s 18-month sunset clause is as meaningful as a decree telling the coronavirus to disappear. Remarkably, we are poised to soon provide MAID for mental illness to marginalized populations practically based on less evidence than required for approval of any sleeping pill. If we want to provide MAID to people with life-suffering illnesses who might get better, we should have that honest debate, and the framework should reflect that. But if it’s meant for irremediable conditions, evidence shows it would be a dishonest and hypocritical deception to offer it for mental illness. Unfortunately, in Canada’s debate about medical assistance in dying, evidence has already been provided a medically assisted death. Dr. K. Sonu Gaind is an associate professor at the University of Toronto, chief of psychiatry at Humber River Hospital, and a former president of the Canadian Psychiatric Association. Editor's note: Due to an editing error, an earlier version misstated the author's gender. The Hill Times

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Evidence lacking to support inclusion of mental illness in assisted-dying framework

If we want to provide MAID to people with life-suffering illnesses who might get better, we should have that honest debate, and the framework should reflect that.

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