‘We’re not ready’: Experts clash over euthanasia for mental illness

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Dr. Donna Stewart doesn’t see herself as a “MAID expansionist,” though she’s been called worse. “Some of this has been pretty unpleasant.”

During a grand rounds lecture, a gathering of medical faculty and trainees to discuss timely issues and medical cases, a psychiatrist presenting on medical aid in dying for mental illness displayed Stewart’s photo, identified by name, along with viral photos from the storming of the U.S. Capitol, including of the horned headdress-wearing rioter known as the “QAnon Shaman,” and a noose hanging from makeshift gallows. The accusation being, “that I did not respect democracy and ignored science,” Stewart said.

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“This was somebody I had never met, a colleague I had never met,” said Stewart, a senior scientist at the Toronto General Hospital Research Institute, a practising psychiatrist for 50 years with a long publication history, who has also performed more than 300 assessments for medical assistance in dying requests, mostly for terminal physical conditions.

With an issue as contentious as euthanasia — voluntary, doctor-administered lethal injection — for those whose sole underlying illness is a mental disorder, Stewart isn’t surprised by the diversity of opinion.

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“But I am a little concerned that some of my colleagues seem to make this a life mission to make sure it doesn’t happen.”

With the deadline for opening assisted suicide to Canadians with a mental illness only a short five months away, a fresh clash has erupted within psychiatry. Both sides accuse the other of bad science, misinformation and unsupported claims. Seven of 17 chairs of psychiatry have written to federal Health Minister Mark Holland and Justice Minister Arif Virani urging the Trudeau government to once again hold off expanding MAID for mental illness. Those who oppose any further delays are being labelled ideological expansion activists; those pushing for the planned expansion to be paused indefinitely are being accused of over-stating how treatable some mental illnesses are.

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“I think there is a kind of grandiosity to thinking you can cure everybody,” said Stewart, who sat on the federal government’s expert panel on MAID and mental illness.

“In spite of the very best efforts, sadly, some psychiatric patients simply do not get better.”

Those opposed to proceeding argue that key issues haven’t been addressed, including whether it’s possible to accurately predict “incurability,” or a particular person’s long-term chances of recovery. “The evidence shows that we are right less than half the time,” said Dr. Sonu Gaind, chief of psychiatry at Sunnybrook Health Sciences Centre in Toronto.

“That means that at least half the people who assessors say, ‘You’re not going to get better from your mental illness, and you can get MAID,’ at least half of those people would have gotten better. Meaning, we would have provided death under a false pretence.”

“There is no consensus on this issue,” Gaind said. “I firmly think we’re not ready for further expansion.”

Some psychiatric patients simply do not get better

A special joint parliamentary committee on MAID reconvened this week to assess just that, the country’s preparedness for a “safe and adequate” expansion of assisted suicide to the mentally ill.

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“MAID is a deeply sensitive topic, and our government is committed to making sure we get it right,” Christopher Aoun, Holland’s press secretary said in an email to National Post.

MAID deaths overall have been increasing 30 per cent, year-over-year, topping 13,200 deaths in 2022.

Two weeks ago, MPs voted against Conservative MP Ed Fast’s private member’s bill that would have rendered MAID for mental illness null and void by amending the Criminal Code to recognize that a mental disorder “is not a grievous and irremediable medical condition for which a person could receive medical assistance in dying.”

The bill was narrowly defeated by 167 to 150 votes.

Parliament’s joint MAID committee has been relaunched to verify the “degree of preparedness” for the introduction of MAID for the mentally ill, before the sunset clause on MAID for mental disorders comes to an end March 17, 2024 — a deadline that had already been extended for a year to provide more time to support health-care system “readiness.”

Since then, a national accredited, federally funded curriculum on MAID has been launched by the Canadian Association of MAID Assessors and Providers, including a module devoted to MAID and mental illness. A task group of experts convened by the government has drafted a model regulatory standard aimed at harmonizing MAID practice across Canada, including assessing requests for a mental disorder, when such requests become lawful next March.

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“More has been done to get ready for this than any other health practice,” said Montreal psychiatrist Dr. Mona Gupta, the task group’s chair.

The standard is meant to guide doctors and nurse practitioners. The seven psychiatry chairs are troubled that it doesn’t carve out a requirement that a psychiatrist must be involved in the assessment process for MAID cases involving mental illness. They argue that no accepted definition of  “irremediability” for mental disorders exits and that extra safeguards to protect vulnerable groups disproportionately affected by mental disorders are still lacking.

Dr. Jitender Sareen, the head of psychiatry at the University of Manitoba. File

Too much is being left in the hands of MAID assessors and providers, said Dr. Jitender Sareen, department head of psychiatry at the University of Manitoba. “Offering people death instead of appropriate treatments really goes against what we as a society should be doing.”

Sareen said guidance is also lacking on how or whether doctors can distinguish between someone who is actively suicidal and someone who is making a rational request for MAID but who isn’t in a period of crisis.

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In a rebuttal letter to the federal ministers, Gupta and the task force members argue that MAID practitioners must already handle suicidality in all types of MAID requests when people seeking MAID say they’ll complete suicide if they aren’t found eligible, or who request MAID after making a suicide attempt or who have a history of suicidal thinking.

There’s also no accepted definition of “irremediability” for any disorder, physical or mental, said Gupta.

While it won’t be true in every case, in most cases of MAID for mental illness the appropriate expert to call on will be a psychiatrist, she said. In others, the person with the best expertise might come from geriatrics, addiction medicine or some other area of medicine, she said.

The practice standard, as well as the Criminal Code, also make clear that a MAID request must be motivated by suffering caused by their medical condition, and not social circumstances, Gupta said.

“You can’t say, ‘This group has a higher rate of X problem, so exclude the whole group.’

“If you have a mental disorder and you are unstably housed and you make a request for MAID, of course that should be considered and investigated,” Gupta said. “But I’m not sure why that process is harder or different or impossible compared to somebody with cancer who is unstably housed or homeless.”

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“I don’t know that it matters what the majority or a minority or a small group of psychiatrists think,” Gupta said. “This is not about us. This is not about our opinions. This is about those individuals who wish to make a request, which is their charter protected right.”

A new study involving 30 people with mental illness and 25 family members found that MAID was seen as the same as suicide, because the end result is death, but a more dignified, safer and less stigmatizing alternative to suicide.

Stewart doesn’t know how the issue is going to play out politically. She doesn’t feel comfortable being cast “as somebody who is really totally committed to making this thing a go,” she said.

“I think it’s going to be a tiny, tiny number who qualify. But they at least deserve a sober look.”

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