Dr Sonu Gaind: Canadian Psychiatric Association (CPA) position on euthanasia for psychiatric reasons is embarrassing

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Sonu Gaind

Dr. K. Sonu Gaind is an associate professor of psychiatry at the University of Toronto, a past president of the Canadian Psychiatric Association (CPA) and a member of the Council of Canadian Academies expert advisory group on MAiD responds in the CanadianHealthcareNetwork.ca to the new position of the CPA supporting euthanasia.

Dr Gaind was the president of the (CPA) at the time of the Carter Supreme Court of Canada euthanasia decision. In response to the Supreme Court decision, the CPA held a task force, developed guidelines and provided evidence based guidance to policy makers and government committee's on euthanasia for psychiatric conditions.
 
In his recent article: I wish I didn't have to write this Gaind expresses his embarrassment by the new position by the CPA that that supports euthanasia for people with psychiatric conditions.

Gaind comments on his personal position on MAiD:

When I started all this, as CPA president in late 2015, I entered with an open mind and as neutrally as I could, both to respect my role as representing not just myself but all CPA members, and also on a personal level I did not want any pre-judgements to form my opinion without understanding the various issues and evidence. I am not a conscientious objector to MAiD in general, and in fact am physician chair of our hospital MAiD group, overseeing all the MAiD cases we undertake. However, after this extensive period of review, it is clear to me now that expanding MAiD for sole criterion mental illness would not be safe in the current context.

Gaind comments on how the euthanasia expansion advocates ignore a basic point of the law.

Expansion advocates often focus overly narrowly on issues they label as “patient autonomy” (even there the focus is on a narrow concept of what autonomy is, rarely acknowledging relational autonomy or other concepts beyond autonomy being what one individual is asking for at one point in time). However, they gloss over the simplest yet most crucial fallacy regarding potentially providing MAiD for mental illnesses. Our current MAiD framework is supposed to be for irremediable conditions. As I’ve written previously in Medical Post and elsewhere, and as CAMH has concluded, irremediability cannot be predicted for mental illnesses at this time. This is presented clearly following extensive evidence-based review in the recent Expert Advisory Group on MAiD report at www.eagmaid.org.

So, if patients with sole criterion mental illness receive MAiD, they are not getting it for a predictably irremediable condition, as they would be if they had ALS, cancer, or other medical conditions with known pathophysiology. They would be getting MAiD because society has agreed they had suffered enough, but they could get better. To me, it is discriminatory to expose those with mental illness to death based on assessors’ personal views and arbitrary opinions of irremediability, when the evidence tells us we cannot predict irremediability in mental illness.

Gaind then suggests that the new CPA euthanasia policy was developed in secrecy. He states:

...Many colleagues with senior positions in CPA leadership roles were unaware of any work CPA was continuing to do on this file (myself included, having completed my term and rotating off the board in September 2019). Despite having been chair of the sunset time-limited CPA task force on MAiD, and an expert on the CCA panel, CPA had not engaged me or any colleagues I know of with expertise in the area to assist with the file. Of more concern, since the 2016 CPA member survey done by the previous time-limited task force on MAiD, which showed only approximately 30% of Canadian psychiatrists supported MAiD for mental illness, there had been no subsequent engagement of general membership regarding their views as issues evolved.

Knowing that the six-month period after the Truchon ruling was coming up in March, and that federal government reviews were intended to start in summer 2020, I contacted the CPA CEO in mid-February to provide CPA with relevant informational updates, and to ask what the CPA was doing on this file given imminent policy changes. Other than a polite response from the CEO over a week later acknowledging receipt of my message, no information was forthcoming (other than confirmation that no-one representing CPA even phoned in on the national, open teleconference lines providing technical briefings on Bill C-7 on February 24).

Gaind continues on the new CPA position statement:

Imagine my surprise when, this past Friday, March 13, the CPA released a so-called Position Statement on Medical Assistance in Dying developed by the CPA Professional Standards and Practice (PSP) Committee. From a process point of view, this raised significant concerns, given the complete lack of member engagement on this issue preceding this statement. The PSP is a generic (i.e., not MAiD-specific) committee of several members (seven). It is unclear whether any additional expertise in the area of MAiD and mental illness was even sought through this process. If it was, it was certainly a well-kept secret from many of us who are CPA members.

Process aside, if such a Position Statement actually provided evidence-based guidance, it could still be of value. Unfortunately, not only does the PSP Position Statement fail to provide any evidence-based guidance regarding MAiD and mental illness, at this critical time when policies are being set, the Statement is actually, in my opinion, damaging and dangerous.

Dr Gaind explains his criticism of the CPA position statement:

The bulk of the one page (if you remove author affiliations) PSP Statement, consisting of five points, makes ‘apple pie’ comments referring to “having working knowledge of legislation,” being “mindful of the medical ethical principles as they relate to MAiD,” being “rigorous in conducting capacity assessments,” and providing information even if choosing to not be involved with provision of MAiD. It also makes a statement that “patients with a psychiatric illness should not be discriminated against solely on the basis of their disability, and should have available the same options regarding MAiD as available to all patients.” That’s it. No actual guidance on what any of that means. And quite remarkably for a Position Statement issued by a national expert professional medical association, after there have been years of focused review and study on the issue (for example, the CCA Panel Reports, and numerous and ongoing other national and international literature references), there is not a single reference to any citation regarding mental illness and MAiD, capacity or decision making, suffering, or above all, irremediability. Again remarkably for a psychiatric association, the three only citations are to Bill C-14 and the Carter and Truchon rulings.

Dr Gaind continues on why the new position is dangerous:

Had the PSP Position Statement simply been unhelpful, I would not have written this piece. Unfortunately, beyond being unhelpful, the Statement is dangerous. While the comment that patients with mental illness should not be discriminated against is self-evident, it is far from evident what CPA is actually saying with that comment. Does this mean that it would be discriminatory to not provide MAiD to patients with sole criterion mental illness? Or does this mean that it would be discriminatory to provide MAiD in such situations, since it would expose patients to arbitrary and unscientific determinations of irremediability that cannot be predicted? Again, remarkably for a psychiatric association, the PSP Position Statement never even once addresses or comments on the issue of predicting irremediability in mental illnesses.

Even worse than taking a position, the CPA has chosen to attempt to say nothing on this issue—and in doing so, in this politicized debate CPA has opened the door to dangerous and arbitrary interpretations of what this position statement actually means (perhaps fittingly, if they have also opened the door to expose patients to dangerous and arbitrary determinations of irremediability of mental illness that cannot be scientifically made).

Dr Gaind states that the CPA position on euthanasia for psychiatric reasons is embarrassing:

As a past president and current Distinguished Fellow of the CPA, it pains me to write this piece. I know how thoughtful, considered and hardworking all elected CPA Board members are. Many are my friends. However, my obligation to all our patients, and to what our members should expect of a member association, must outweigh these feelings. Through the process and content of this PSP Position Statement, by failing to engage or be respectful of its own members, by failing to even try to address any evidence-based recommendations and being silent on key issues needing guidance regarding mental illness and MAiD at this crucial time, the CPA has failed its members and our patients in its role as a national professional member association, and has in fact abrogated its role and lost any moral authority in this important issue.

Today, I am embarrassed to be a CPA member.

More information on this topic:

• Article: Canadian Psychiatric Association approves euthanasia (Link). 
• Article: Is euthanasia psychiatric treatment? (Link).
• Article: Why legalizing medical assistance in dying for people with mental illness is misguided (Link).
• Article: Canada's Justice Minister says that euthanasia may be extended to people with mental illness (Link). 
• Article: Quebec court expands euthanasia by striking the terminal illness requirement. Euthanasia for psychiatric reasons is next (Link).  
• Article: Psychiatrists must prevent suicide, not provide it (Link).
•  Article: Physically healthy depressed man died by euthanasia in BC (Link). 
• Article: Dr Mark Komrad: Why psychiatrists should oppose euthanasia (Link).
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