A group of Canadian psychiatrists, including those who have been involved with medical assistance in dying (MAiD), several University and Hospital Department Chairs and several past Canadian Psychiatric Association presidents respond to a recent piece in Impact Ethics that criticized calls to exclude patients with mental health disorders.

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A recent piece, “Canadian Psychiatrists Respond: MAiD and Mental Disorders”, contained troubling inaccuracies we must address.

The authors of that piece claim that not providing state-facilitated suicide for sole mental illness is “discrimination”, echoing claims by Senator Stan Kutcher. The opposite is actually true. MAiD is for irremediable medical conditions, ones that can be predicted to not improve. Worldwide scientific evidence shows assessors cannot predict irremediability in cases of mental illness, meaning that this eligibility criterion cannot be met. Even precision modeling predictions show such predictions are wrong over half the time. Evidence shows we cannot distinguish suicidal ideation caused by mental illness from motivations for MAiD for mental illness (indeed, overlapping characteristics suggest there may be no distinction to make). Those with mental illness have higher rates of psycho-social suffering. Combined, this could mean that MAiD assessors will be wrong over half the time when predicting irremediability, will wrongly believe they are filtering out suicidality, and will instead provide death to marginalized suicidal individuals who could have improved. That is the ultimate discrimination.

Photo Credit: needpix.com. Image Description: A person holding the hand of another individual in a hospital bed.

The authors of the November 15 commentary misleadingly claim Canada would be an outlier by not providing assisted suicide for mental illness, writing “apart from Canada and Québec, no jurisdiction that allows assisted dying has specifically excluded people with mental disorders”. The authors must know many jurisdictions allowing MAiD only provide MAiD for near end-of-life conditions (Canada’s own initial law contained a reasonably foreseeable natural death eligibility criterion), thus do not require separate safeguards protecting individuals from assisted suicide for sole mental illness since these conditions would not qualify. The revised law doesn’t include the “reasonably foreseeable natural death” safeguard, which is precisely why a safeguard excluding MAiD for sole mental illness becomes necessary. The few jurisdictions allowing MAiD for mental illness have safeguards Canada lacks, notably (unlike Canada) requirement of due care and no reasonable alternative, or treatment futility, prior to MAiD eligibility.

Rather than learning from other countries’ experiences, all of which have more safeguards than Canada, the authors manipulate these details and erase known dangers.

The authors manufacture a distracting straw person argument that excluding MAiD for mental illness “is based on the paternalistic assumption that [patients] cannot make autonomous decisions”. Most people with mental illness retain capacity to make autonomous decisions. However, even when patients can make autonomous choices, the problem with MAiD for mental illness assessments is not about patient autonomy. The problem with these assessments is about hubris of the assessor.

It is unprofessional for assessors to claim they can predict irremediability of an individual’s mental illness, qualifying them for death by MAiD, when all evidence demonstrates such predictions are usually wrong. It is unscientific for assessors to claim they weed out suicidality from psychiatric MAiD requests when evidence shows those distinctions cannot be made. And it reflects perspectives of privilege when assessors, including university professors demanding evidence for everything else, ignore evidence showing marginalized populations are particularly at risk of premature death by assisted suicide for mental illness.

One of the authors, a key government advisor, once testified “it doesn’t concern [her]” that twice as many women as men get assisted suicide for mental illness in Europe, since “nobody really knows (what it means)”. Most psychiatrists know that same 2:1 gender gap exists with double the women attempting suicide when mentally ill (most do not die by suicide and do not reattempt) – raising obvious concerns about gender-based marginalization potentially fueling a 100% lethal outcome by MAiD in suicidal women.

Several authors sat on Expert Panels and Working Groups that failed to recommend safeguards to protect vulnerable marginalized Canadians from wrongful deaths by MAiD. The author quoted above chaired and others sat on the 2022 federal Panel, which refused to recommend any additional legislative safeguards, and refused to recommend any minimum number, types or lengths of treatment before providing assisted suicide for mental illness, despite Canada’s laws not requiring past access or attempts at treatment before MAiD. Their Panel claimed society had made an “ethical choice” to provide MAiD even if MAiD and suicide were not distinct entities. Two members of the 12 member Panel resigned, including the health care ethicist and a member with lived experience, citing lack of safeguards and the Panel Chair’s activism as flaws.

Zealous assessors operating in an environment devoid of standards or safeguards is problematic. Another author, member of the 2022 Panel, and the Canadian Psychiatric Association Working Group on MAiD, acknowledged on CBC radio the unpredictability of assessing irremediability of mental illness, reframing the issue as one of autonomy, indicating she would inform the patient their prognosis was uncertain and let them make “an informed choice” about MAiD. Yet presumably on the federal, self-reported, documentation she would attest the patient had an irremediable condition (failing to do so risks non-compliance with the Criminal Code) rather than an uncertain prognosis.

In the 2016 E.F. case, E.F. received MAiD for conversion disorder (unexplained physical symptoms presumed to be psychological in origin) after another author testified as an expert witness that E.F.’s situation was irremediable, and that E.F. had capacity (was competent) to get MAiD. However, the psychiatrist’s assessment was based on chart review, he never met nor spoke with E.F. Most psychiatrists recognize the impossibility of determining capacity without communicating with a patient. When surveyed, only 5% thought chart review was sufficient for such MAiD assessments. This case, which occurred prior to the introduction of MAiD legislation, highlights dangers posed by lack of standards. Ironically, the author in question also sits on the Canadian Psychiatric Association Working Group on MAiD, ostensibly tasked with providing guidance on these issues.

The author who has chaired federal Panels and developed so-called “Model Practice Standards” suggested Canadians should not worry about MAiD expansion because no assessor has been prosecuted in Canada. We disagree that the absence of prosecution is the measure of whether adequate safeguards are in place – dead people do not complain, and family members have experienced notorious difficulty taking concerns about potentially improper MAiD provisions forward.

Canadians have received faulty reassurances, but effective safeguards do not actually exist, and evidence does not support the planned 2024 expansion of MAiD to mental illness. The Globe and Mail editorial board is right – Canada should halt the planned expansion.

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K. Sonu Gaind (Ontario), Major Bertrand (Quebec), Martin Chisvin (Ontario), Harvey Chochinov (Manitoba), Peter Czaplinski (Manitoba), Paul Dagg (BC), Sarah Danial (Ontario), Timothy Ehmann (Ontario), Joel Eisen (Ontario), Natasha Fernandes (Ontario), Pierre Gagnon (Quebec), Sarah Garside (Ontario), Gabriella Gobbi (Quebec), Randy Goossen (Manitoba), Jaswant Guzder (BC), Jack Haggarty (Ontario), Angela Ho (Ontario), Andrew Howard (BC), Trevor Hurwitz (BC), Andrea Iaboni (Ontario), Laila Jamal (Ontario), Mark Katz (Ontario), Laurence Kirmayer (Quebec), David Koczerginski (Ontario), Marshall Korenblum (Ontario), Ted Lo (Ontario), Jodi Lofchy (Ontario), Kathy Margitai (Ontario), Fiona McGregor (BC), Ian Musgrave (Ontario), Karin Neufeld (Ontario), Michael Passmore (BC), Ivan Poukhovski-Sheremetyev (Ontario), Francois Primeau (Quebec), Jeff Reiss (Ontario), Hugues Richard (Ontario), Ed Rzadki (Ontario), Jitender Sareen (Manitoba), Anton Scamvougeras (BC), Mary Seeman (Ontario), Allan Steingart (Ontario), Sephora Tang (Ontario), and Stan Yaren (Manitoba) are Canadian psychiatrists.