Temas de Capa

Euthanasia and mental illness: To avoid a painful death or to avoid a painful life?

euthanasia - milenio stadium

 

Canada will soon offer doctor-assisted death to the mentally ill. In March 2023, people whose sole underlying condition is depression, bipolar disorder, personality disorders, schizophrenia, PTSD or any other mental affliction will be able to qualify for the procedure. With tangible illnesses such as terminal cancer, there is something inside the body that can be seen and measured, but when it comes to mental illnesses, they can’t be detected with a scan. The ambiguity grows even more if we consider the fact that many mental health issues walk side by side with feelings of despair and suicide. To understand this complex matter, we asked Dr. K. Sonu Gaind – MD, FRCP(C), DFAPA, professor at University of Toronto and former president of the Canadian Psychiatric Association – about the underlying issues of medical assistance in dying for mental illness.

 

Dr. K. Sonu Gaind - milenio stadium

 

Milénio Stadium: The laws that allow euthanasia for patients with mental illness are very recent. How was the legalization received by the mental health professionals community?
K. Sonu Gaind: First, I should point out that I myself am not a conscientious objector, I supported MAiD (Medical Assistance in Dying) as it was introduced in 2016 for those whose deaths were reasonably foreseeable. However I believe our current MAiD expansion allowing euthanasia for sole mental illness is misguided. In terms of my colleague psychiatrists, there is a range of opinion but I believe most share my views. The most comprehensive survey of psychiatrists on the topic to date showed most psychiatrists who responded oppose euthanasia for sole mental illness. I helped develop this survey with others on the Ontario Medical Association Section on Psychiatry, and we presented background information arguing both for and against MAiD for mental illness in an unbiased way. We found that although 86% of psychiatrists supported MAiD in some situations (so they are not “conscientious objectors” to MAiD in general), by a two to one margin psychiatrists opposed MAiD for sole mental illness. The gap was even bigger for those with the strongest views on either side, with psychiatrists who strongly disagreed with MAiD for sole mental illness outweighing those who strongly agreed with it by a three to one margin. When asked specifically whether they agreed with the current “sunset clause” that requires MAiD for mental illness to be provided by March 2023, psychiatrists opposed the sunset clause by a three to one margin.
The gap was even greater for those with strong views, and psychiatrists strongly opposing the sunset clause outnumbered those strongly supporting it by a five to one margin. So while there is a range of views, anyone, or any group, suggesting there is any consensus in psychiatry supporting MAiD for sole mental illness is incorrect.

MS: Several mental health conditions are connected to suicidal behaviours. While many organizations work to prevent suicides, providing helplines and support, canadian law now allows voluntary death for psychiatric conditions. How thin is this line between helping someone to keep living or to die?
KDG: This depends on the situation the person is seeking death for. Under the previous law, before the expansion by Bill C7 of MAiD to non-dying disabled, death needed to be reasonably foreseeable to get MAiD. Research shows that in near end of life situations, people seek MAiD for different reasons than people who are traditionally suicidal, and you can tell these issues apart. In these situations, people are seeking MAiD to avoid a painful death. When you expand MAiD beyond the near end of life, and provide it to the non-dying disabled and to those suffering solely from mental illness, that line you are talking about is not thin, it entirely disappears.
Research shows we cannot distinguish those seeking psychiatric euthanasia from those who are suicidal as a result of their mental illness, which impacts how we think even while we remain competent. In these situations, instead of seeking MAiD to avoid a painful death, many seek death to avoid a painful life. Even more troubling, evidence from the few European countries currently allowing psychiatric euthanasia shows the risk of facilitating suicide in these situations is even higher for marginalized populations. Most people receiving psychiatric euthanasia have unresolved psychosocial suffering like poverty or loneliness, and a gender gap also emerges of twice as many women as men seeking and being provided psychiatric euthanasia.
Any psychiatrist should find this gender gap terrifying, since it parallels the two to one gender gap of women to men who attempt suicide when suffering from mental illness, who would benefit from suicide prevention strategies. Most of these women will not actually die by suicide, and most do not re-attempt it. So with psychiatric euthanasia, evidence suggests that for some people, especially the most marginalized with life suffering, we are actually taking a situation where someone may have suicidal wishes, which may last for a long period of time but still be temporary, and converting these non-lethal attempts into a permanent death by MAiD, which is 100% lethal.

MS: How hard is it to determine if a patient is eligible for this procedure when dealing with the ambiguity and non tangibility of mental health conditions?
KDG: This question depends on whether you mean how hard it truly is, based on science and evidence, or whether you mean how hard it will be in practice in Canada, when left up to individual assessors. Remember that the public has been told MAiD is supposed to be for “irremediable” medical conditions (i.e. when we can predict the condition will not improve). In terms of science and evidence, it is clear that there is no science or evidence that mental illness can be predicted to be “irremediable” in individual cases, in fact just the opposite.
Any scientific group that has reviewed the situation has concluded this, including CAMH which concluded that “At any point in time it may appear that an individual is not responding to any interventions – that their illness is currently irremediable – but it is not possible to determine with any certainty the course of this individual’s illness. 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.” We do not even understand the underlying biology of most mental illnesses, we certainly can’t predict when they will not improve. This is very different from other medical conditions like cancer, or neurodegenerative conditions like ALS or Alzheimers. While individual assessors may believe they are capable of predicting irremediability of mental illness, science and evidence tells us they are wrong – their predictions are no better than chance, or flipping a coin. However in practice, it may be surprisingly easy to consider someone eligible for MAiD when the government starts providing psychiatric euthanasia in March 2023. The recent federal panel that was charged with providing safeguards and protocols for how to provide MAiD for mental illness failed to provide any specific guidance for determining “incurability” or “irreversibility”. The panel stated “It is not possible to provide fixed rules for how many treatment attempts, how many kinds of treatments, and over what period of time” treatment should be required before providing death by MAID for mental illness. Instead of safeguards, the panel provided non-specific general principles and suggested this decision be made on a “case-by-case basis”, and felt that “no further legislative safeguards are required”. These recommendations expose patients to arbitrary unscientific assessments based on ideological values of assessors, and reassurances are not safeguards.
Perhaps most remarkably, the panel even acknowledged that suicide and psychiatric euthanasia could be the same thing, writing that “society is making an ethical choice to enable certain people to receive MAiD, regardless of whether MAiD and suicide are considered to be distinct or not.” Two people of the initial twelve member panel resigned, including the panel’s health care ethicist who publicly wrote that “in good conscience” he could not sign off on the panel’s recommendations. Getting back to your question, despite the fact that science and evidence tell us it is not in reality possible to predict irremediability of mental illness, in practice when there are no standards or actual safeguards set to determine irremediability of mental illness it may be surprisingly easy for individual assessors to (wrongly) make conclusions of eligibility.

MS: Do you think that more patients will think of medical assisted death as the answer for their problems compared to the time when it was not legal?
KDG: Evidence shows this is happening already. MAiD was introduced in 2016. Every year since the death rates by MAiD have gone up across the country. By 2019 the death rate had risen to 2%, meaning that 2% of all Canadians who died that year died by state sanctioned euthanasia (and in the vast majority of MAiD cases in Canada, it is euthanasia i.e. when the medical practitioner provides the injection leading to death).
By 2020 the rate had gone to 2.5% of all deaths, and in 2021 it was 3.3% of all Canadian deaths, with some provinces approaching 5%. And all this was before the government expanded MAiD to the non-dying disabled, so pretty well all those MAiD deaths were in situations when death was reasonably foreseeable (the expansion to non-dying disabled happened part way through 2021, but evidence shows it takes some time for rates to adjust to new policies, and only 2.2% of 2021 MAiD deaths were for the newly opened non-dying disabled pathway). These numbers will surely increase in coming years as euthanasia for non-dying disabled is provided, and for sole mental illness by March 2023. The reality is we know that, when you make something easier to do (including death), more people do it.

MS: Does the legalization of this practice represent a shift in the deep ethics of psychiatry?
KDG: As I discussed earlier, I do not think the current legalization of psychiatric euthanasia reflects the opinions of most psychiatrists. However, many are also reluctant to speak out since they fear potential backlash from those who have advocated strongly for euthanasia expansion. Many expressing caution have been labelled by expansion activists as being paternalistic or even discriminatory, under the false claim that it would be “discrimination” if euthanasia wasn’t provided to those suffering from sole mental illness.
Ellen Cohen, a mental health advocate with lived experience who was one of the panelists who resigned from the recent federal panel, testified last week that she was shamed in this way by another panelist when she expressed cautions. I myself have had colleagues attempt to stifle or suppress my presentations, and have faced significant backlash for voicing my concerns. In terms of “discrimination”, in my mind it is discrimination to provide death by MAiD based on subjective guesses of individual assessors, wrongly predicting a condition as being irremediable during periods of a patient’s despair, when we cannot predict who will actually get better.
In terms of a deep shift in ethics in psychiatry, if most psychiatrists actually supported this then yes, I think it would reflect a deep shift. If that were to happen, I would label it the Pinocchio Syndrome – that in our drive to be considered “a real illness”, we would be ignoring the very real differences between mental illness and other illnesses on issues related to death, and simplistically saying that the only way to be considered “legitimate” would be to considered “the same”.
Mental illnesses are real illnesses that can lead to significant suffering, and they should be treated with legitimacy; but if our drive for legitimacy comes at the sacrifice of evidence, and of our most vulnerable and marginalized suffering patients, that would be a serious ethical dilemma. However as above, whatever is driving these policies to provide psychiatric euthanasia, it is not based any consensus in psychiatry. If anything, those supporting this expansion are the outliers, regardless of whether they happen to hold leadership or other positions. Finally, thank you for taking the time and interest to explore this challenging topic. I think public engagement and awareness is essential, these discussions touch on deep and profoundly complex issues. For those interested in more on this topic, the Expert Advisory Group on MAiD published an evidence-based review in 2020, and an updated 2022 parliamentary brief, which can be found at www.eagmaid.org. In my view, as I wrote a year ago in an article for The Conversation (online blog), I fear with our precipitously expanding MAiD laws we are setting ourselves up for a future national apology.

Telma Pinguelo/MS

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