This article was published in The Globe and Mail on February 25, 2023.
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| Scott Kim |
By Scott Kim
Now that the Canadian government has introduced a bill to delay implementing psychiatric MAID – assisted dying for people whose sole underlying condition is a mental illness – this is a good time to step back and reflect on how Canada got here. Last week’s release of a joint parliamentary committee’s report on MAID only adds to the need for such reflection.
The proposed delay of one year for psychiatric MAID [Medical Assistance in Dying] followed increasing numbers of reports of people forced to “choose” MAID for lack of basic resources, and of doctors and caseworkers initiating unsolicited conversations about the procedure with patients who, understandably, found such talk inappropriate.
Last February, for example, a woman reportedly chose to die after years of failing to find affordable housing that would allow her to avoid the household chemicals that triggered her conditions. Meanwhile, Veterans Affairs Canada has acknowledged that at least four veterans were recommended, or in some cases “pressured,” to have MAID by a department caseworker in situations where, for the most part, they were not inquiring about it; that case has been turned over to the RCMP for investigation.
Warnings from psychiatric leaders and newspaper editorial boards, as well as a 2021 rebuke by the United Nations Human Rights Council about the potential for discrimination against those with disabilities, could no longer be ignored.
One ought to be outraged by desperate, vulnerable people being forced to choose MAID, their lives terminated by health care professionals for social and economic reasons. But why did Canada reach this crisis point in the first place?
Why indeed. After all, the relevant facts are hardly a revelation.
It is not news that a significant proportion of the public struggles with mental illness. It is not news that such people often lose hope and perspective, which often leads them to wish for death. It is not news that about 4,500 Canadians end their own lives every year, with probably 20 times that number attempting the same, and with an even greater number who wish for death without taking action; most of them have some form of mental illness.
So the number of vulnerable persons who might consider psychiatric MAID is large – we’ve known this. And we’ve known that for many people in need, the Canadian health care system – despite its admirable features – fails to cover even basic elements of mental-health care, such as psychotherapy and prescription medications, much less adequate disability supports.
Then there are the facts we’ve gleaned from research on psychiatric MAID in jurisdictions where it has been legalized. My team’s studies of Dutch cases of psychiatric MAID have shown that people who request the procedure, and people who attempt and die by suicide, have very similar clinical profiles. Our research also demonstrates that women request and receive psychiatric MAID at over twice the rate of men – the same ratio of women-to-men suicide attempts. This is what one would expect if a 100-per-cent lethal method, such as MAID, were used as a means of suicide.
Only 5 percent to 10 percent of requests for psychiatric MAID are granted in the Netherlands, in large part because of the Dutch requirement that MAID be a last resort – a protection missing in Canada. We also know, from a Belgian study of 100 consecutive patients referred for psychiatric MAID evaluation, that the desire for the procedure can be highly unstable; even when psychiatric suffering is deemed to be “chronic, constant and unbearable, without prospect of improvement,” the majority of requestors changed their minds, eventually “managing with regular, occasional or no therapy.”
Further, we know that doctors are not very good at predicting whether even patients labeled as having “treatment-resistant” depression will in fact not respond to future treatments. And a 2016 study of Dutch psychiatric MAID cases that my team conducted found that evaluations to ensure that the patients are competent enough to request the procedure are in fact rather cursory in practice.
I could go on.
Policy makers in Canada have heard all this; the information has been shared widely in committees and legislatures and courtrooms for years. So it is a surprise that MAID providers have been telling lawmakers that the number of people seeking MAID for mental illness will be small, and that a government expert panel specifically tasked with devising safeguards apparently saw no need to issue any, causing two members to resign in protest. The government’s announcement to delay psychiatric MAID is a clear confirmation of that panel’s utter failure.
Is the problem that Canada has the most permissive MAID regime in the world? Well, not exactly. After all, Swiss adults have fewer legal restrictions on receiving assisted death.
Instead, the problem is on the provider side. The debate in Canada has not focused enough on why well-meaning doctors are continuing to approve and perform such outrageous cases of MAID. Aren’t doctors supposed to protect the vulnerable? Are they not guided by an ethic, a professional identity that goes beyond the floor set by the law? What is happening to Canadian medicine?
The answer is that it has been captured by a uniquely Canadian MAID ideology. The current crisis cannot be averted without addressing this potent driver of Canadian MAID practice.
Consider the controversy over doctors and staff initiating unprompted conversations with patients about MAID. Such incidents are understandably disturbing because no one should suggest to another person – especially someone living with a disability – that their life is not worth living.
So it is striking that Canada’s main MAID-provider organization, the Canadian Association of MAiD Assessors and Providers (CAMAP), has been promoting the practice of bringing up the procedure unsolicited. The organization, which received C$3.3 million from the government to develop a curriculum for MAID providers, has set this out as not merely something permissible, but as a “professional obligation.”
It is difficult to overemphasize how radical this position is.
Such unprompted initiations of MAID conversation are prohibited in the Australian state of Victoria, and in New Zealand (both jurisdictions in which the procedure is legal). One does not have to be a fan of gag rules – and, to be clear, I’m not – to see that such prohibitions are meant to draw attention to a clear boundary: Even when MAID is legal, it should be an exception to the practice of medicine, not something to be taken into its very bosom. There is a reason why all MAID laws regulate how to respond to requests, not how to promote it.
But in Canada, aided by a flawed law, a MAID ideology is transforming the way medicine views itself. To talk of ideological capture in Canada is not hyperbole.
Consider a patient who still has good (even curative) treatment options left, but who refuses them and requests MAID instead. In the Netherlands, a doctor who believes that the patient indeed has genuine options would be violating not only the law but also their professional ethic as a doctor if they sign off on MAID in such a case. Since MAID is a last-resort exception there, a Dutch doctor must exercise their professional medical judgment to determine that no medical intervention will alter the outcome for the patient.
In contrast, a Canadian doctor faced with a MAID request from a patient with a curable disease can put aside such an ethic (or, as one psychiatrist in such a situation put it in an interview with The Globe and Mail, go “against her better judgment”) and terminate the patient’s life. Why would well-meaning Canadian doctors discard their professional ethic? Why do they not feel the force of it to guide their practice?
To see why, we only need to return to the CAMAP document on bringing up MAID with patients. CAMAP repeatedly calls MAID a “treatment option” and a “care option” that is “medically effective.” This kind of Orwellian word game has chilling consequences. MAID is now a treatment option that a doctor may provide instead of even a curative option; after all, both are “medically effective” care options.
Through this ideological lens, it is easy to see why a doctor might approve MAID for even those who desperately want to live but cannot afford to. The doctor need not feel they are abandoning the patient to poverty and despair – even as common moral sense tells us that is what is happening – since they are offering what has been described as a medically effective treatment.
It is therefore chilling to see that the recently published report from the Special Parliamentary Joint Committee on MAID approvingly mentions that CAMAP – the leading proponent of this ideology – is developing “training materials” that will “help standardize approaches to MAID assessment across Canada.”
Under this ideology, it is as though the Canadian Constitution, through the Supreme Court, invented a magically effective medical product that is always at the ready. This ideology has co-opted and transformed the country’s health care system into the most potent vehicle for MAID delivery in the world – with no safeguard but the personal discretion of providers. It makes it easy to argue for no special oversight beyond personal discretion, since it is just another medically effective treatment.
In the Netherlands, every single MAID case is reviewed by an interdisciplinary committee, and transparent oversight is the goal. For example, in 2013, when psychiatric MAID became a focus of public debate, this committee published anonymized reports of every case from that year. Compare this with some Canadian providers who seem less concerned about transparency, and who privately discuss the problem of poverty-driven MAID but publicly deny it as “clickbait.”
Reasonable people may disagree about whether MAID should be legal. But one need not be for or against the procedure to see that it should be considered a tragic last resort, and that calling it a medically effective treatment is an especially cruel form of gaslighting.
As we have seen, this MAID ideology – one shared by no other jurisdiction in the world – has made fact-based policy making nearly impossible in Canada. Unless its spell is broken, it is difficult to see how a further deepening of the crisis can be avoided, for no set of “safeguards” born from the ideology will be able to protect the society’s most vulnerable from the “helping hand” of medicine.
Scott Kim is a psychiatrist and philosopher who studies medical assistance in dying. He served on the Council of Canadian Academies Expert Panel Working Group on MAID Where a Mental Disorder is the Sole Underlying Medical Condition.
