The danger of extending medically assisted death to the mentally ill

David Lametti is Minister of Justice and Attorney General of Canada.

The number of medically assisted deaths has increased substantially since MAID (medical assistance in dying) legislation was introduced in 2016.

And Canada is now set to become one of the first nations in the world to allow patients to seek such a death on the basis of a mental health condition.

According to a Statistics Canada report released January 10:

In 2017, 2,838 medically assisted deaths were reported by Health Canada, compared with 4,478 deaths in 2018. In 2019, there were 5,425 medically assisted deaths in Canada, accounting for 1.9% of all deaths.

In 2020, this increased to 7,383 deaths (2.4% of all deaths in Canada), representing a 36.0% increase in the number of MAID recipients from 2019 to 2020.

Those numbers are likely to continue climbing quickly. Alex Schadenberg, Executive Director of the Euthanasia Prevention Coalition wrote April 12:

Canada expanded its (MAID) euthanasia law by passing Bill C-7 in March 2021, Many people are unaware that one of the bill’s provisions legalized euthanasia for people with mental illness alone. This means that a person who is not physically ill or dying but is living with mental illness can be killed by euthanasia.

At that time the federal government put a two-year moratorium on euthanasia for mental illness to enable the government to establish protocols for this category of killing. I have stated that the two-year moratorium is unenforceable making euthanasia for mental illness legal already.

;Tristin Hopper gave an overview of the situation in an April National Post comment.

Euthanasia was legalized in Canada in much the same way as abortion: The Supreme Court struck down existing bans on the practice and then gave Parliament a time limit to draw up some guidelines.

In the case of abortion, a 1988 Mulroney government attempt on an abortion bill was defeated by the Senate, which is why Canada still doesn’t technically have any legal limits on terminating a pregnancy.

In the case of euthanasia, in 2016 Parliament passed Bill C-14, a bill that restricted euthanasia to Canadians whose death was “reasonably foreseeable.”

At the time, there was agreement among the Liberal-dominated House of Commons that the bill  should not apply to the mentally ill. “This will not apply to minors and especially not to those suffering from mental illness. Those people are far too fragile,” Conservative MP Gérard Deltell (a self-declared supporter of medical assistance in dying) said at the time.

It was a stance that incensed supporters of euthanasia, and even sparked an 11th hour attempt by the Senate to expand the eligibility criteria to include Canadians not necessarily on death’s door. Nevertheless, Senators withdrew after receiving pushback from MPs.

If the House of Commons seemed intransigent on the issue, they did seem to be reflecting the public mood: A survey of 529 psychiatrists conducted in 2017 found that while 72 per cent of psychiatrists supported medical assistance in dying, just 29.4 per cent supported it for issues of mental illness.

What changed was another court decision, this time from the Quebec Superior Court, which struck down the “reasonably foreseeable death” provision as being unconstitutional. The federal government didn’t appeal the decision and instead passed Bill C-7, which expanded the eligibility for euthanasia including – starting in March 2023 – assisted dying for Canadians whose “mental illness is the sole underlying medical condition.”

Both Schadenberg and Hopper pointed to a lengthy assessment of  the MAID situation by Sharon Kirkey. Schadenberg quoted her at length, beginning with a quote by Dutch research psychiatrist Dr Sisco van Veen who says that mental illness cannot be identified like other diseases:

You can’t see depression on a scan. With the exception of dementia, where imaging can show structural brain changes, “in psychiatry, really all you have is the patient’s story, and what you see with your eyes and what you hear and what the family tells you,” van Veen says.

Most mental disorders lack “prognostic predictability,” which makes determining when psychiatric suffering has become “irremediable,” essentially incurable, particularly challenging. Some say practically impossible . . .

. . . In the Netherlands, MAID for irremediable psychiatric suffering has been regulated by law since 2002, and a new study by van Veen and colleagues underscores just how complicated it can be. How do you define “grievous and irremediable” in psychiatry? Is it possible to conclude, with any certainty or confidence, that a mental illness has no prospect of ever improving? What has been done, what has been tried and is it enough?

Kirkey outlines the government time-table on euthanasia for mental illness:

Sometime in April, an expert panel struck by the Liberal government to propose recommended protocols for MAID for mental illness will present its report to the government. A joint parliamentary committee studying the new MAID law has been given a mandate to report back by June 23.

The expert panel’s chair declined an interview request, but her 12-member assembly has been tasked with setting out proposed parameters for how people with mental illness should be assessed for and – if found eligible – provided with MAID, not whether they should be eligible.

Kirkey speaks to Dr Sonu Gaind, a critic of euthanasia for mental illness.

For Dr. Sonu Gaind, a past president of the Canadian Psychiatric Association, the most fundamental safeguard has already been bypassed, because there is no scientific evidence, he says, that doctors can predict when a mental illness will be irremediable. Everything else goes out the window.

Gaind isn’t a conscientious objector to MAID. He’s the physician chair of the MAID team at Humber River Hospital in Toronto, where he’s chief of psychiatry. He works with cancer patients. He’s seen the positive, the value that MAID can bring. But unlike cancer, or progressive, neurodegenerative diseases like ALS, “we don’t understand the fundamental underlying biology causing most major mental illnesses.”

“We identify them through the clustering of various symptoms. We try to target treatments as best we can. But the reality is, we don’t understand what’s going on, on a fundamental biological level, unlike with the vast majority of these other predicable conditions.”

Without understanding the biological underpinnings, what do you base your predictions on, he asks. He’s heard the argument that it’s difficult to make firm predictions about anything in medicine. But there’s a world of difference between the degree of uncertainty between advanced cancers and mental illnesses like depression, he argues.

“There’s no doubt that mental illnesses lead to grievous suffering, as grievous, even more grievous in some cases than other illnesses,” Gaind says. “It’s the irremediability part that our framework also requires and that scientifically cannot be met. That we cannot do. That’s the problem.”

Go here for Kirkey’s full article.

ARPA Canada posted two good comments about MAID earlier this year:

* MAID providers give themselves permission to provide more euthanasia

* Looking back at a report on MAID and mental illness

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