Belgian nursing Professor exposes euthanasia practice.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Eric Vermeer

I found an interesting Spanish article concerning Eric Vermeer, a Belgian professor of nursing, psychotherapist and specialist in palliative care and psychiatry. Vermeer wrote a chapter in a book that was recently published featuring 10 euthanasia experts. I google translated the article from Spanish.

The article explains that in the past 10 years the number of reported euthanasia deaths has tripled from 954 to 2655. Those numbers do not include the euthanasia deaths in Belgium that are not reported. The article then states that in 2019 17% of the reported euthanasia deaths were done to people who were not terminally ill. The article states:

In addition, it is known that in 2019 at least some 450 who died (17%) were not terminally ill, that is, they did not have diseases that were rapidly approaching death. That, is in the official figures. Presumably, there were many more in undeclared euthanasia.

Vermeer refers to studies indicating that almost half of the Belgian euthanasia deaths are unreported and he confirms that this remains a problem by refering to Dr Marc Cosyns who, 5 years ago, said in the Senate that he had long since stopped declaring his euthanasia deaths and he also stopped calling another colleague to validate the euthanasia request as required by law.
 

Belgian rally against euthanasia

In reference to the fact that after 20,000 reported euthanasia deaths there have only been 2 conflicting cases, Vermeer states that:

The "controls" are carried out by euthanizing physicians and supporters of this practice. What is clear is that the users (that is, the dead) do not complain after the "service".

Vermeer is stating that the euthanasia committee is composed of euthanasia doctors and supporters. He says that it is hard to uncover abuse since the dead don't complain.

Vermeer explains that euthanasia began as a "last resort" for terminal states and excruciating pain, but now it works for everything and doctors and even nurses offer it to vulnerable and depressed people very lightly. He provides a few examples to illustrate his point.

- A lady with severe cancer, but is still a long way from death; She complains about her alcoholic husband and her twenty-something daughters who do not visit her. Her attending physician asks her: "Given your health and family situation, do you not think that euthanasia could be the least bad solution?"

- A divorced woman with chronic depression has attempted suicide three times; the psychiatric nurse, when she arrives at the hospital after her last suicide attempt, says "do you know you can request euthanasia?"; the depressive suicidal woman asks the nurse for more information and she gives her the data of an association promoting euthanasia.

- An older lady has been cared for in a residence for years; a stroke has just left her speechless, although she is conscious; An assistant, in an evaluation meeting of the team that cares for her, comments naturally: "Can't we propose euthanasia to this woman? She is greatly diminished after that attack"

Vermeer explains that the Belgian law does not permit doctors or nurses to propose euthanasia, but they do it anyway.

Vermeer then examines euthanasia for psychiatric reasons in Belgium. He states:

In 2001, when the Belgian euthanasia law was being debated, the Justice Commission that promoted it ensured that "patient's with only psychiatric suffering can never lead to euthanasia, patients with dementia or psychiatric disorders do not fall within the scope of the law" (Descheemaecker Report of the Justice Commission).

But in the 2014-2015 report, 108 people were euthanized for depression, early-stage dementia, bipolar disorder, schizophrenia, anorexia...

It is another example of the dangerous slope: the standard that was promised now accepts euthanizing people who are depressed (and suicidal).

He provides several examples of psychiatric euthanasia cases:

The case of a woman who was narrowly saved. Laura, 24 years old, with chronic depression, requests euthanasia. Three doctors say he has "irreversible psychic suffering." The month required by law passes, the doctor arrives to euthanize her and she says no, that she no longer wishes to die.

A bipolar girl fails in her second suicide attempt and the doctor on duty suggests euthanizing her. The girl is in a rage: "Don't you see that I'm nothing but shit? My adoptive parents have rejected me and I'm alone in the world!"

Nancy, a woman who was not loved by her mother and kept repeating to her "I wish you had been a boy." Nancy Verheist had a sex change, went on to declare herself "Nathan", but her mother still did not want to. So Nancy asked for euthanasia, and the Belgian State, instead of attending to her psycho-emotional problems, undertook to eliminate it medically in 2013.

Vermeer is concerned about euthanasia for psychiatric reasons. The article states:

Vermeer, like other experts in psychic health, knows that the concept of "irreversible psychic suffering" is scientifically very problematic.

Also, the law requies a person be "capable and conscious" to request euthanasia ... is a depressed person or a psychotic "capable and conscious"?

Links to more articles on euthanasia in Belgium.

• More than 40% of Belgian euthanasia deaths went unreported in 2013 (Link). 
• Belgian doctor admits to not reporting euthanasia deaths (Link).  
• More than 1000 Belgian deaths were hastened without request (Link).  
• Healthy 24-year-old woman (Laura) who was approved for euthanasia will live (Link).  
• Physically healthy 23-year-old Belgian woman is being considered for euthanasia (Link).  
• Depressed Belgian woman dies by euthanasia (Link).
•  Belgian twins euthanized out of fear of blindness (Link).
•  Belgian woman with anorexia nervosa dies by euthanasia (Link). 
• Is euthanasia a psychiatric treatment? (Link).  
• Why psychiatrists should oppose euthanasia (Link).
•  Belgian 2018 euthanasia report. 247% increase since 2010 (Link).
  

Does Bill C-7 prevent euthanasia for mental illness?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Petition: Reject euthanasia Bill C-7 (Link).

Many people have stated that Bill C-7 prevents euthanasia (MAiD) for mental illness alone. Recently the Canadian Bar Association End of Life Working Group, that support euthanasia for mental illness, recommended that:

Mental illness should not be excluded from the definition of “serious and incurable illness, disease or disability”.

I am convinced that Bill C-7 already permits euthanasia for mental illness. 

People have said, Bill C-7 does appear to prevent euthanasia for "mental illness". Section (2.‍1) of the bill states:

For the purposes of paragraph (2)‍(a), a mental illness is not considered to be an illness, disease or disability.

This section of Bill C-7 will not prevent euthanasia for mental illness or psychological reasons alone because it does not define the terms "mental illness" or "psychological suffering."

Let me explain.

Previous to the Quebec Truchon court decision, a person didn't qualify for MAiD based on psychological reasons alone since the law required that a person's "natural death be reasonably foreseeable," which was not defined.

Canada's euthanasia law states that a person qualifies for euthanasia (MAiD) if:

the illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.

By eliminating the "reasonably foreseeable death" requirement, the court decision eliminated the "terminal illness" requirement but also expanded euthanasia to people with psychological conditions alone. Unless defined, mental illness will be defined to be a form of psychological suffering.

What does Bill C-7 do?

1. Bill C-7 removes the requirement in the law that a person’s natural death be reasonably foreseeable in order to qualify for assisted death. Therefore, people who are not terminally ill can die by euthanasia. The Quebec court decision only required this amendment to the law, but Bill C-7 went further.

2. Bill C-7 permits a doctor or nurse practitioner to lethally inject a person who is incapable of consenting, if that person was previously approved for assisted death. This contravenes the Supreme Court of Canada Carter decision which stated that only competent people could die by euthanasia.

3. Bill C-7 waives the ten-day waiting period if a person's natural death is deemed to be reasonably foreseeable. Thus a person could request death by euthanasia on a "bad day" and die the same day. Studies prove that the “will to live” fluctuates.

4. Bill C-7 creates a two track law. A person whose natural death is deemed to be reasonably foreseeable has no waiting period while a person whose natural death is not deemed to be reasonably foreseeable would have a 90 day waiting period before being killed by lethal injection.

5. As stated earlier, Bill C-7 falsely claims to prevent euthanasia for people with mental illness. The euthanasia law permits MAiD for people who are physically or psychologically suffering that is intolerable to the person and that cannot be relieved in a way that the person considers acceptable. However, mental illness, which is not defined in the law, is considered a form of psychological suffering.

More Articles on Bill C-7:

• Stop the extension of euthanasia by Bill C-7 (Link).
• More than 15,000 Canadians have died by euthanasia (Link).
• Canadians oppose euthanasia for mental illness and child euthanasia (Link).

Conceiving the inconceivable: assisted suicide for people with mental illness.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Thank you to Dr Mark Komrad for sharing this superb paper by Bernardo Carpiniello published in the Journal of the Italian Society of Psychiatry. Carpiniello works in the Department of Medical Sciences and Public Health-Unit of Psychiatry, University of Cagliari Italy.

Carpiniello's paper - Conceiving the unconceivable: ethical and clinical concerns over assisted suicide for people with mental disorders is a significant paper dealing with the concerns related to euthanasia for psychiatric reasons. 

Carpiniello recognizes that only a few jurisdictions in the world have legalized euthanasia and assisted suicide and in these jurisdictions only a small number of these deaths done to people with mental illness. 

Carpiniello points out that only 34% of Dutch physicians will participate in euthanasia for mental disorders.

Polling data indicates that there is more opposition by Dutch psychiatrists to psychiatric euthanasia with 53% of psychiatrists opposed to euthanasia for mental illness in 1995 and 63% in 2015. He suggests that the drop in support for psychiatric euthanasia is related to moral distress. He states:

Euthanasia or assisted suicide represents a typical example of a situation in which psychiatrists are faced with the impossibility of having to reconcile two moral obligations, a duty of care and respect of patient autonomy. To put it bluntly, for many psychiatrists euthanasia is ethically unacceptable, particularly as the main aim of psychiatry is to limit patients’ suffering.

Carpiniello then points out the position of the American Psychiatric Association.

“the American Psychiatric Association, in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death”

Carpiniello expresses his concern for the growth of euthanasia in countries where it is legal.

Euthanasia has been reported as a typical example of the “slippery slope, down which we have rolled to now allow something that was impossible to conceive as ever being acceptable”

Based on the increase in the number of euthanasia deaths and the expansion of acceptable reasons for euthanasia, I agree that incremental extensions will occur, if legalized.

Carpiniello tackles the question of suicide prevention, a primary public health concern. He quotes from the WHO Director-General, Tedros Adhanom Ghebreyesus stated:

“despite progress, one person still dies every 40 seconds from suicide. Every death is a tragedy for family, friends and colleagues. Yet suicides are preventable. We call on all countries to incorporate proven suicide prevention strategies into national health and education programmes in a sustainable way”

Carpiniello indicates that suicide prevention and suicide assistance are irreconcilable.

Indeed, an emphasis on suicide prevention from a public health perspective seems to be somewhat hard to reconcile ...for those countries simultaneously equipped with social and health policies established for the specific purpose of preventing suicide. Considering the specific role of psychiatry in preventing suicide, put in very simple terms the question is: what is the point of psychiatrists trying in every way possible to prevent suicide if the person concerned is entitled by law to seek assistance to commit this action?

Carpiniello examines the clinical concerns related to psychiatrists approving euthanasia. He points out:

“assessments of competency, sustained wish to die prematurely, depressive disorder, demoralization and ‘unbearable suffering’ in the terminally ill are clinically uncertain and difficult tasks ... As yet psychiatry does not have the expertise to ‘select’ those whose wish for hastened death is rational, humane and ‘healthy’

He explains that there are no objective measures to determine if someone has lasting or unbearable suffering.

Further to that Carpiniello finds that it is impossible to determine if treatment is futile for the patient. He states:

How can we confirm that a single case should definitely be considered untreatable if “there are no universal standards defining incurability in most cases of mental illness” and “there is no reliable mechanism to define incurable disease and determine medical futility for psychiatric care

He points out that there is no definition for the condition known as treatment resistant depression (TRD). He states:

it could prove an arduous task, even for the most experienced psychiatrist, to confirm that the case undergoing evaluation for assisted suicide is an actual TRD, ...Accordingly, it should be kept in mind how approx. 20% of Dutch patients requesting euthanasia had never undergone psychiatric hospitalization, 56% had refused some form of recommended treatment, and how in 27% of cases patients had requested assistance with dying from a physician who had not previously been involved in their treatment.

He continues by quoting from a study indicating that the majority of TRD patients get better.

More recently, 155 TRD patients were evaluated over a 1-7 year (median 36 months) follow-up, revealing how 39.2% of follow-up months were asymptomatic and 21.1% at sub-threshold symptom level, while 15.8% featured a mild, 13.9% moderate, and 10.0% severe depressive episode level, thus demonstrating how the majority of patients with TRD manage to achieve an asymptomatic state.

Further to that, he shows how there is no standard to assess competence or decisional capacity amongst these patients. He quotes from a study that was based on information from the Dutch Regional Review Committees that found:

in their evaluations physicians frequently stated that psychosis or depression did (or did not) affect capacity but provided little explanation to corroborate their opinions. The findings of this study once again raised a series of doubts as to the reliability of evaluation of decisional capacity of patients requesting EAS, at least in the Netherlands.

He then examines the phenomenon of transference and countertransference that exists in a therapeutic relationship with a patient and he states:

Some authors have criticized the assumption according to which a physician will always act in the interests of their patients, mostly because it fails to consider the doctor’s unconscious, and at times conscious, desire for the patient to die and alleviate distress for all concerned, including the physician. ...Doctors who are affected by countertransference or who have psychologically committed themselves to PAS may be prone to accepting patients’ reasons for PAS at face value without thorough exploration”

He then explains how physician/patient relationships can lead to pseudoempathy. He states:

One of the most frequently cited consequences of countertransference is over-identification with the patient, giving rise to a so-called ‘pseudoempathy’, a condition resulting in the physician experiencing the feeling that the patient’s suicidalwish is ‘normal’ and that they would feel the same way.

Carpiniello examines what he calls, the undesiralbe consequences of assisted suicide. He sites several concerns including:

• “... will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients? If so, how far will the influence of that belief spread?”
• data from the Netherlands, reports “56% of cases in which social isolation or loneliness was important enough to be mentioned in the report”, arguing that “the latter evokes the concern that physician assisted death served as a substitute for effective psychosocial intervention and support”
• EAS in psychiatric patients may be detrimental in the advancement of research and implementation of new treatments, given that it “may reinforce poor expectations of the medical community for mental illness treatment and contribute to a relative lack of progress in developing more effective therapeutic strategies” 
• “What consequences on social representations of mental illnesses, on how to deal with a mental illness and on professional profile if psychiatrists recognize that life with mental illness – even if “only” in individual cases – is not worth living?

Carpiniello concludes that no firm conclusions can be drawn based on data related to euthanasia for psychiatric reasons.

Carpiniello's paper clearly indicates that the negative consequences related to euthanasia for mental disorders suggest that this should not be done.

Dr Mark Komrad: "Psychiatrists prevent suicide, not provide it."

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Mark Komrad

There are many great doctors working to prevent euthanasia and assisted suicide, but Psychiatrist and ethicist, Mark Komrad, has excelled in his research, leadership and talking points.

Duke University School of Medicine Alumni Magazine recently featured Dr Komrad's career, accomplishments and his opposition to euthanasia and assisted suicide.

Komrad told Aliza Inbari, from the Alumni Magazine:

“I feel that killing does not belong in the house of medicine, should not be a part of palliative care, and especially not for psychiatric patients. 

Psychiatrists prevent suicide, not provide it.”

Dr Komrad was featured in the Fatal Flaws film where he poignantly stated that:

"if assisted death were done with a gun, then it would be universally seen as wrong."

Inbari explained Komrad's opposition to euthanasia and assisted suicide:

Physician-assisted suicide is legal in some countries in Europe, Canada, and in several U.S. states. In most places, physician-assisted suicide is allowed only in cases of terminal illness, but a few jurisdictions, notably Belgium and The Netherlands, allow patients with mental illness access to the procedure. Komrad is deeply opposed to the practice. 

“I found it profoundly disturbing that in Belgium and the Netherlands, a significant number of psychiatric patients every year are voluntarily euthanized by their own treating psychiatrists,” says Komrad.

Inbari states how Komrad's opposition to euthanasia and assisted suicide has changed his life.

The issue has transformed his career from ethicist to activist, and he has become one of the leading figures in the country expressing ethical concerns about this issue. Komrad has addressed the parliaments of Sweden and Norway, met with policymakers in Brazil, and consulted to the government of Canada, and he lectures at conferences and psychiatry departments around the country.

Thank you Dr Komrad, for your leadership and dedication.

Links to some of the excellent articles by Dr Mark Komrad:

• Why Psychiatrists should oppose euthanasia (Link).
• Euthanasia and assisted suicide are unethical acts (Link).
• Psychiatrists: We prevent suicide not provide it (Link).
• Why Norway and Sweden should not allow assisted suicide (Link).
• Assessing competency for assisted suicide is unethical (Link).

Belgian Catholic hospitals that provide euthanasia will cease being Catholic.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

In April, 2017; 15 Belgian psychiatric hospitals that are operated by the Belgian Brothers of Charity, announced that they would allow euthanasia in their institutions.

Soon after, Br Rene Stockman, the superior general of the Brothers of Charity, said he was devastated by the news and asked the Vatican to intervene in this case.

According to Zenit news, in August 2017, the Vatican sent a letter to the Belgian Brothers of Charity condemning euthanasia and ordered them to stop euthanasia in their psychiatric institutions.

The Congregation for the Doctrine of the Faith (CDF) has ordered the Belgian Brothers of Charity to cease identifying the psychiatric hospitals as Catholic institutions now that they permit euthanasia.

According to CNA news the letter from the CDF from March 30, 2020 stated:

"with deep sadness" the "psychiatric hospitals managed by the Provincialate of the Brothers of Charity association in Belgium will no longer be able to consider themselves Catholic institutions."

CNA news also reported that Brother René Stockman the superior general of the Brothers of Charity, said that "with a heavy heart" the religious congregation "must let go of its psychiatric centers in Belgium."

More information on this topic:

• Article: Is euthanasia psychiatric treatment? (Link).
• Article: Why legalizing medical assistance in dying for people with mental illness is misguided (Link).
• Article: Psychiatrists must prevent suicide, not provide it (Link).
• Article: Dr Mark Komrad: Why psychiatrists should oppose euthanasia (Link).

Canadians oppose euthanasia for mental illness and child euthanasia. Canada must reject Bill C-7.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Petition: Stop euthanasia Bill C-7 (Link)

On February 24, 2020 Canada's federal government introduced Bill C-7, an act to amend the Criminal Code (medical assistance in dying). 

Bill C-7 is the federal government's response to the Quebec Court decision that struck down the section of Canada's euthanasia law requiring that "natural death be reasonably foreseeable" to qualify for death by euthanasia (lethal injection).

Bill C-7 amends the euthanasia law by eliminating the "terminal illness" requirement, allowing advanced requests for euthanasia, and removing the 10 day waiting period. It also falsely claims to prohibit euthanasia for mental illness.

Bill C-7, a bill to amend Canada's euthanasia (MAiD) law, if passed without amendments, will make Canada's euthanasia law the most permissive in the world.
 
Bill C-7, appears to be designed by the results of the online survey that was conducted in January 2020. On January 14, I urged EPC supporters to participate in the Canadian Department of Justice Medical Assistance in Dying consultation questionnaire. In my article I stated:

The language of the consultation questionnaire is not great, nonetheless, the questionnaire allows you to leave further comments.

On January 15 I published a Guide to answering the Questionnaire. The guide had more than 19,000 page views.

The assessment of the public consultation on Medical Assistance in Dying provides greater clarity concerning Bill C-7.

According to the consultation indicates that, Canadians don't want euthanasia for mental illness or child euthanasia. The assessment of the public consultation states:

Theme 4 - Concerns with expanding eligibility for MAID

Comments under this theme included concerns with expanding eligibility for MAID to those who suffer from mental illness and mature minors.

A majority of those who provided comments were not in favour of extending MAID to people who suffer from mental illness. They expressed concerns that people with mental health issues, such as depression, may feel that MAID is their only option, when effective therapies could lead to full recovery. Rather than extending the option to terminate lives, many respondents felt that the focus should be on increasing preventative measures, supports, resources, and intensive treatment for people with mental health issues, as well as increasing resources for people with physical disabilities. Some noted that people with mental illness, and those with physical and intellectual disabilities, are especially vulnerable to manipulation and abuse, or may feel like a burden on family, friends or the healthcare system, and suggested different and specific qualifying criteria for these groups.

In contrast, others felt that people suffering from mental illness should be eligible for MAID in certain circumstances (e.g., chronic, severe, disabling, treatment-resistant disorders). Some noted that mental health conditions can result in suffering that is as painful as physical disorders and not respond to treatment, resulting in people making dangerous suicide attempts rather than ending their life in a safe way.

Most respondents did not support MAID being extended to minors due to their state of development and the risk that they would make an irreversible decision and die before their time. Others were in support of extending MAID to minors in cases of terminal and incurable diseases, with proper safeguards in place.

Theme 4 explains why Bill C-7 did not extend euthanasia to children and why the government claims that the bill prevents euthanasia for mental illness. Sadly, Bill C-7 does not prevent euthanasia for mental illness.

I reported, in September 2019, that the Quebec court expanded Canada's euthanasia law by eliminating the requirement that only terminally ill people could be killed by lethal injection.

By eliminating the "terminal illness" requirement, the court decision also expanded euthanasia to people with psychological conditions alone. Canada's euthanasia law states that a person qualifies for euthanasia if:

the illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.

Before the Quebec court decision, a person didn't qualify for euthanasia based on psychological reasons alone since the law required that a person's "natural death be reasonably foreseeable." Since the Quebec court struck down this requirement, the law now permits euthanasia for psychological reasons.

Bill C-7 pretends to prevent euthanasia for "mental illness". Section (2.‍1) of Bill C-7 states:

For the purposes of paragraph (2)‍(a), a mental illness is not considered to be an illness, disease or disability.

This statement does not prevent euthanasia for mental illness or psychological reasons since the law specifically permits it. To prevent euthanasia for "mental illness" the bill would need to properly define "mental illness."

The government has previously stated that it plans to have an official five-year review of the euthanasia law starting in June 2020.

The federal government needs to reject Bill C-7 and conduct a proper review of the law, as promised, starting in June 2020.

Petition: Stop euthanasia Bill C-7 (Link).

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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