MAID for Mental Illness: Myths & Facts

Revised March 21, 2021

Background: As a result of the 2019 Truchon decision in a lower court in Quebec, a revised Medical Assistance in Dying (MAID) law (Bill C-7) is now being considered by our federal parliament. The proposed legislation removes the “death being reasonably foreseeable” requirement and is opening the door for physician assisted suicide for people who are not terminally ill.

Some persons with mental illness, by virtue of brain disease that often includes symptoms of hopelessness and suicidal thinking, have long been recognized as potentially vulnerable to suicide inducement and, until now, have rightfully been excluded from eligibility for MAID. Suicide prevention is recognized as a critical mental health service necessary to preserve life. The Senate recently proposed an amendment that will eliminate this broad protection and allow state-sanctioned suicide for these vulnerable people, starting in 18 months. The Liberals are proposing adding just 6 more months to that time frame. The reality is that neither time frame can produce non-existent clinical evidence in support of the naïve legal position that doctors can magically predict irremediability for mental illness.

Myth: Deciding who will get MAID for mental illness will not be a guessing game.

Fact: The expert panel being constituted by the Liberal government can’t manufacture evidence that doesn’t exist in the universe. No one can know what is unknowable. Everyone can state over and over that some people with mental illness must have irremediable mental illness. But no one can identify precisely who these people are. Not you. Not any experienced psychiatrist. Unless they guess. Or unless they mean by irremediable that someone hasn’t gotten better when their suffering is considered at a certain point in time (as would be true of everyone at given points). What point in time? During the year they are waiting for psychiatry services? During the 5 years they are waiting for sub-specialty psychiatry care? During the endless amount of time they are waiting for non-existent intensive case management? Or a place to live? During the time they are waiting for the standard treatment that the government hasn’t funded? During the time disease induced hopelessness has kept them from seeking help? During the time their disease has impaired their insight into the fact they need help? Start the timer!

How many die by suicide while waiting for months or years for any mental health services?

How many die by suicide after being discharged prematurely from in-patient psychiatry?

How many die by suicide because they are unwilling to go to the ER and be treated with disrespect and disdain again?

How many die by suicide because they are labelled a “drug seeking problem”?

How many die by suicide after being sent home from the Emergency Room?

How many die by suicide because of suffering wrought by abject loneliness?

How many die by suicide because of the suffering wrought by poverty?

How many die by suicide because of stigmatization and social rejection?

How many die by suicide because of homelessness?

How many die by suicide because their families can no longer cope with their symptoms?

How many die by suicide because they saw a story about suicide in the media?

How many die by suicide because of inexperienced doctors?

How many die by suicide because of misdiagnosis?

How many die by suicide because their doctor doesn’t seek advice from sub-specialist colleagues?

How many die by suicide because they live in a rural community and have inadequate treatment?

How many die by suicide because of the psychiatrist shortage? (over 200 positions unfilled at hospitals in Ontario)

How many die by suicide because of poor treatment by their own doctor who has internalized the same stigmatization and judgement of other Canadians?

How many die by suicide because they feel their life just doesn’t matter to anyone?

How many will refuse treatment because MAID will be a faster, easier, doctor-supported alternative to healing?

How many will die by MAID who could live a good, long life instead?

You don’t know the answer to these questions? Neither do I. Neither will the members of the expert panel being set up to give our country the “MAID for Mental Illness How-to Manual”. But that won’t stop them from writing the rules for the guessing game as though they do. Let’s play the odds they will say. If you have suffered a long time and tried some treatments that is good enough. It won’t matter whether it was provided in time to prevent brain damage from your degenerative disease, or the right treatment even, or whether your suffering was because of poverty or loneliness or homelessness, or whether you kept refusing treatment offered. It won’t matter because wrong guesses won’t be exposed from the grave.

“Canada, the Guessing Game Capital of the World”

Myth: The Justice Minister/Attorney General of Canada didn’t mislead Canadians.

Fact: One of the most extraordinary things about the last few months in the flow of events that led to the House of Commons passing Bill C-7 (by a vote of 180-149) on March 11, 2021 was that an Attorney General of Canada, David Lametti, sworn to uphold the laws of the land, and his Parliamentary Secretary, MP Arif Virani, repeatedly made statements that were clearly misleading. And then other Liberals repeated them over and over in their written and verbal “talking points”.

In November, parliament and the small group of Canadians that were even aware of what was happening (what with a pandemic on our minds) were told three things:

1. MAID for mental illness is excluded from Bill C-7
2. The exclusion of mental illness is consistent with the Charter.
3. There is no consensus among expert mental health clinicians or organizations on whether MAID should be offered for mental illness.

In February, when examining the bill, the Senate made up completely new legislation and added MAID for mental illness to begin in 18 months. The bill went back to the House of Commons where the Liberals accepted the new legislation (and said 24 months to implementation instead of 18.) They said a year to study ways to implement it (implementation being a foregone conclusion) and then the second year to operationalize it.

What is remarkable, as all other political parties except the Bloc decried, is that:

1. The Senate made new law. It did not simply reflect on, or make suggestions on, the existing law. This is not the Senate’s legislative role. This is the unelected tail wagging the elected dog.
2. The Liberals allowed this new law without any of the standard House of Commons parliamentary committee work that studies new law, without any public consultation process on the new law, and without first listening to Canadian experts and mental health organizations.
3. Then the Liberals and Bloc rammed this through the House of Commons with a closure motion that shut down debate and allowed for only a few hours of discussion. The only reasonable interpretation is that they feared further dissent in their own ranks (7 Liberals did not support the bill, which took real courage given a party apparatus that expects conformity) and they feared being exposed for what they had done. They were enacting new law without proper consultation with anyone. The few weeks between the February 2021 Senate amendment and the March 11, 2021 passage of the bill gave no time for consultation nor was it even considered. 

And so, in contrast to just a few months ago, the Attorney General of Canada is now saying:

1. MAID for mental illness is included in Bill C-7
2. The inclusion of mental illness is consistent with the Charter.
3. There is consensus among expert mental health clinicians or organizations on whether MAID should be offered for mental illness.
4. The government has already consulted widely and had hundreds of hours of testimony and input.

When did this magical consensus appear? When did the specific consultations on this new law occur? In fact they didn’t.  The testimony heard previously was never in relation to the new law. It couldn’t have been because the new law didn’t exist! The previous testimony was from hundreds of disability organizations. Their testimony was ignored. For mental illness the Liberals just skipped a step and didn’t even have to pretend they listened.

The Prime Minister has said over and over during COVID that the government follows the advice of experts and the science. They didn’t in this case. They didn’t even ask us.

A couple of years ago the Canadian Council of Academies advised against MAID for mental illness. CAMH, CMHA, and myriad mental health organizations are already on record as being against it. On March 11, when a Conservative MP in the House of Commons said he held a letter with 129 organizations objecting, and he asked MP Arif Virani (Minister of Justice spokesperson) to name even one organization that supported the new law, MP Virani was at an obvious loss and then suggested maybe a Quebec psychiatrist group (who by their own admission report their psychiatrists are extremely split) and that Dying with Dignity is in support. Dying with Dignity! A suicide lobby group is what this government offers as support for legislation that facilitates suicide! Utterly shameful!

Will the government stack the expert panel it is creating as it follows through on the charade of safeguards? It would seem it has to, because an otherwise balanced group of experts that understands clinical realities and the science would recommend that the law cannot be implemented because mental illness can never meet the Bill C-7 legal test of irremediability. 

Every Canadian with a disability and every Canadian touched by a personal experience with mental illness should remember this moment at the ballot box. I wonder if the Liberals and Bloc have registered just how many tens of millions of Canadians that actually is?

Myth: Members of Parliament are doing their duty as legislators by complying with the Charter of Rights.

Fact: That is only part of their duty. If the Charter said slavery or eugenics or forced sterilization were the law of the land (all of which have been the case on Canadian soil) MPs duty in the present day would clearly not be to blindly comply with a particular Charter interpretation but rather ensure justice and equality for all. The Charter is a living document subject to judicial interpretation and embodied in just legislation made by just legislators. A presumed and untested interpretation of the Charter mustn’t lead to the abrogation of legislative duty, thoroughness, reflection, and ultimate responsibility to protect all citizens. MPs marching in lockstep in response to Truchon, the Senate amendment, and claims to certainty about the primacy of a particular charter interpretation are all examples of the tail wagging the dog and the dog letting it.

Myth: The 24 month “sunset clause” is a reasonable way to ensure that MAID for mental illness goes ahead safely.

Fact: This should properly be called the “delayed implementation clause”. Approving the 24 month sunset clause is absolutely tantamount in this present moment to saying we already know it must be allowed even though we don’t have any present evidence that it should be allowed. The legal argument must follow from clinical evidence, and not vice versa. Pretending doctors can do something they can’t in order to bolster a legal position is the false manufacturing of evidence.  If evidence in support of clear clinical prognostication existed for these particular brain diseases it would have already come forth through the Canadian Council of Academies exhaustive review, and it would have been loudly confirmed by MAID expansionists. Yet, not one of them actually said we can predict irremediability in any particular patient. They keep saying, like a mantra, that “people with irremediable mental illness deserve MAID”. But they have no data, and no clinical evidence-based means, to identify who these individuals might actually be. Extensive clinical experience tells us that such patients are rare or may not exist except insofar as there are patients who refuse potentially effective treatments and the myriad options for the relief of suffering (the case of EF is a case in point). What ethical doctor would use guesswork when the outcome is certain death? Unfortunately, there are inexperienced psychiatrists, and there will be psychiatrists who are confident with guesswork because no one will ever know if they were wrong. Do we really want legislation that suborns incompetent professional practice?

It comes down to this: Let’s agree there are people with irremediable mental illness. Who are they? Your untrained guess is as good as any psychiatrist. That should worry you.

Myth: It must be a doctor who performs the assisted death procedure because it is a medical act.

Fact: If it is a medical act why is it viewed and operationalized in the United States and Switzerland as a social freedom or autonomous act of citizenship? In those countries it is not a health care intervention, treatment procedure, or part of the medicalized tableau it has become in Canada. In those countries people take the poison pill on their own time, in their own location of choice, and with whomever they wish. In those countries you have to meet certain criteria (e.g. terminally ill) to get the poison pill from your doctor, but after that you are on your own. If you can complete your suicide without a doctor is it still a medical act?

In the US it is illegal to inject the poison to cause death (the person has to take it in pill form) but in Canada that is the preferred method used by 97% of “MAID providers” to date. If the person is in hospital, very near death, can’t swallow, already has an IV line in, I get the practical logic of it. But if you have mental illness and can do it yourself whenever you want, absent medical involvement, what does that tell us about the act itself?

MAID providers say you need someone who can start an IV line…that makes it medical! So anyone who draws blood in a lab can also do it? So anyone addicted to IV morphine or heroin or crack can also do it? So anyone who has a one hour how-to training session can also do it? So any Dying with Dignity volunteer who wants to get good at it can do it? Like getting my Red Cross Death-Aid certificate?

MAID providers say over and over that an IV method causes death faster. I am not sure why 3 hours is better than 7 hours at that point. “Easier on people watching”, they say. Do they really believe that a few hours will in any way assuage the agony of a physically healthy loved one choosing suicide? They also say the person might throw up the pill…again they are talking about people on the cusp of death who are severely physically ill…not a relevant consideration in people with mental illness who are physically able to swallow. Besides, if you throw up, take another pill. The do-it yourself kits can have two pills and a checklist for documents to sign attesting it was uncoerced suicide.

MAID providers say how supportive and comforting and essential the doctor’s and nurse’s presence are. But, again, this is in the context of terminal illness. In the suicide context? Do they help by providing false moral absolution for the person and exoneration for themselves and family members? Do people really believe the psychological dynamics are this simplistic? The Swiss experience confirms substantial traumatization for a lot of loved ones. In a non-terminal context these are not the sweet goodbyes that MAID expansionists fantasize they are.

Myth: “Reasonably forseeable death” should not be a necessary condition for MAID.

Fact:  The MAID law from 2016 (Bill C-14) provides access to MAID for people who have a “grievous and irremediable medical condition.” The term is specified under the law as having the following components: 1) “a serious and incurable illness, disease or disability”; 2) “an advanced state of irreversible decline of capabilities”; 3) which causes “unbearable physical or psychological suffering that cannot be relieved under conditions that the person considers acceptable” and; 4) “the person’s natural death has become reasonably foreseeable, taking into account all medical circumstances, and not requiring a specific prognosis as to how long they have left to live.” 

All these conditions have needed to be fulfilled for MAID to proceed, and thereby limited MAID to the context of terminal illness. Ethicists speak of necessary and sufficient conditions for a course of action to be justifiable. By removing the “death being reasonably forseeable” criterion, the judge in Truchon made a unilateral determination that terminal illness was not a necessary condition for MAID and made the other conditions jointly sufficient. What logic supports making just that particular necessary condition unnecessary? Some would argue that it is not just necessary but also has primacy of importance in any weighting of the four conditions. “If you are dying, what does it matter if you die a few weeks earlier?” “If you are dying soon, that will stop the suffering.” “What does it matter if your disease is remediable (not curable but your suffering can be reduced) if you are going to die in a few weeks anyway?”  

On one interpretation, the logic in Truchon is akin to saying that every Canadian should have access to chemotherapy even if you don’t have cancer, or that every Canadian should have access to a wheelchair even if you have no problem walking.  Having a terminal illness with very little time left to live is in fact a particular physical state that entails multiple ethical, conceptual, and pragmatic considerations that are both particular and unique to it. The current MAID debate and the 50 years of medical ethics literature on euthanasia attest to the different moral and empirical status of the near death context. 

Myth: MAID for terminal illness is the same as MAID for mental illness.

Fact: Terminal illness means sure death and no hope. Mental illness means no death and sustaining hope. Profoundly different states of being. Saying the two are the same for purposes of assisted death is twisting logic in the service of ideology.

With the “reasonably forseeable death” criterion removed in Bill C-7, the use of the “irremediability” criterion is being changed in practice from definitely irremediable to possibly irremediable. Is “possibly” good enough when what is at stake is not 6 months but 60 years?

Some people extrapolate from the “beautiful stories about warm goodbyes” with MAID for terminal illness to a claim that the same will hold true outside the terminal context. On the contrary, the Swiss, Belgian and Dutch experience shows the non-terminal context is fraught with distress (families don’t support the death, families will not participate, families initiate legal action, families still have hope of recovery, families feel abandoned, family members are traumatized – including PTSD).

Myth: There is no distinction between physical and mental Illness when it comes to MAID.

Fact: There are brain diseases that are in the clearly defined domain of psychiatric disorders. Physiologically there is of course a continuum…we have one whole body. And suffering is suffering. However, diagnostically and categorically there is not one continuum. There are 3 treatment categories: physical illness, mental illness, and mixed illness.

Mixed illness includes dementias (e.g. Alzheimers) and certain neurological disorders (e.g Huntington’s) that can meet criteria for terminal disorders.

Clear mental illness is distinguished by the brain diseases that cause psychiatric symptoms: suicidal thinking, abnormal mood, impaired cognition, psychosis, hopelessness…a very specific list of symptoms and symptom clusters. They are not terminal conditions.

Here is another way of telling the difference. With physical illnesses I know when treatment attempts are exhausted, and I make that determination in a medical milieu free of societal stigma. With mental illness:

• Treatment is commonly not available because of stigma
• Treatment is often not begun because of the impact of stigma on the person
• Treatment is often derailed because of the impact of stigma
• Treatment attempts are never exhausted because the treatment arsenal is substantial and healing can take years
• It is impossible to predict which patient may yet recover or have reduced suffering

Myth: The Senate supported an 18 month “sunset clause” because they wisely weighed all of the evidence they heard.

Fact: The preponderance of recent Senate Committee evidence did not support moving forward with MAID for mental illness (hence the Committee’s very thoughtful report). A key issue is the question of establishing whether some mental illnesses can meet the legal test of irremediability. Either there is adequate data to support determinations of irremediability or there is not. If it existed it would have been presented. It does not exist, so it could not be presented. The Committee heard and seemingly understood this. However, in ignoring the Committee report, the majority of members in the full Senate gave unjustified weight to supposition, fallacious reasoning, and/or a political agenda. Furthermore, they are trying to pre-empt the mandated (and COVID delayed) legislative review of Bill C-14; they did not weigh the clear recommendation of the Canadian Council of Academies that advised against proceeding with MAID for mental illness due to lack of data and the limits of clinical prognostication; they did not respect the informed pleas of myriad disability and mental health organizations representing the most vulnerable of citizens; they ignored the grave concerns of Indigenous peoples and the United Nations; and they are trying to bind parliament to a course of action of their own desire with no request for a reference to the Supreme Court.

New information or better reasoning will not miraculously appear in the next 18 months. The Senate has made us an outlier in the world. This is not about social progress, or recognition of a changing world and citizen values. The Senate is ignoring the evidence and sound reasoning put before it. Martin Luther King said his task was to help people see the injustice before their very eyes. I expected better from the senators. I needed better. I can tell you today the names of my patients who will die because of their actions….patients who are gradually healing but plan to stop trying.

Every Canadian citizen already has the right to kill him or herself. MAID for mental illness does not add any new legal liberty and there is no legal “right to death” in our charter.

Of the 100% of Canadians who attempt suicide, only 23% try again, and only 7% complete suicide. MAID for mental illness only serves to make suicide easier. Why does the Senate want suicide to be easier? The Senate has failed in its duty to protect.

Myth: “Bill C-7 must be passed right away because suffering Canadians need relief through MAID as fast as possible!”

Fact: If this is true, then it is also true that universal palliative care must be available as fast as possible, and that universal disability supports must be available as fast as possible, and that universal mental health care must be available as fast as possible, because it is the absence of these that is making some people suffer so much that they want to die rather than live. Why do some people with the power to rectify longstanding discrimination wear a cloak of virtue to hide their disfigured sense of decency?

We can all agree that terrible suffering must be responded to with haste and compassion. Why is it, though, that the many decades of extreme suffering of persons with disabilities and mental illness did not garner this same politically urgent response? Why the focus on MAID and the political pretense that Bill C-7 is the most urgent and best solution? Why was Truchon not appealed to the Supreme Court?

If it weren’t for the COVID pandemic and winter weather Parliament Hill would see the largest protest of Canadians in wheelchairs ever assembled. If it weren’t for poverty and marginalization and the fact most Canadians are unaware of this shocking push for state sanctioned suicide, those protesters would be joined by millions more.

Who do you stand with Liberal Party? You proclaim loudly that you stand with Indigenous peoples but they are telling you this bill that pretends to equality is colonialism in sheep’s clothing. They are saying that this law will kill them in a medical system that is already unabashedly racist. It is another imposition of colonial values being used to crush Indigenous spirituality and mock respect for the sacredness of life.

Who do you stand with NDP Party? You say with the poor and vulnerable…are you pretending not to hear? The disability organizations are shouting loudly into your face.

Who do you stand with Conservative Party? The mentally ill need your help and protection, not the false mercy of state killing.

This “othering”, this heartless stigmatization, this inability to bridge the gulf of ableism, this lack of understanding at the deepest level of our shared humanity, is obvious to those watching from across the gulf… from our wheelchairs and homeless shelters…from our homes that look so placid to passersby but are in reality places of secret sorrow and struggle and hopelessness. What utter tragedy that people in power spouting sham slogans don’t even know what they don’t know.  Blind with eyes wide open. 

Myth: People deserve death with dignity and MAID provides that.

Fact: This debate has distorted what dignity means. Dignity means deserving of honour or respect. What MAID advocates mean by loss of dignity is loss of control, loss of superficial appearance, and self-critical judgement. They have, tragically, subverted the most dignified acts of all: unfailing love and deep respect for each other in all life circumstances. Bathing my dying grandmother, whispered conversations on the threshold of separation, silent reflection and presence through a long night waiting for a last breath…these are the moments of greatest dignity.

Dignity is found within our relationships. It is about whether someone looks at you and treats you with respect rather than with subtle disdain or prejudice, or makes you feel like you are bothering them. Dignity is not about the means of death. Dying with dignity means dying in a milieu of care, love, kindness and respect. Anyone who says all of these things are not present in a natural death setting simply does not understand what dignity is.

Myth: Bill C-7 is not discriminatory.

Fact: Canadian disability organizations, mental health organizations, Indigenous organizations, religious organizations, and the United Nations all say Bill C-7 is absolutely discriminatory because it singles out vulnerable Canadians and offers them the inducement of physician assisted death without offering adequate disability supports or treatment to help them live full lives free of the suffering caused by poor health care, poverty, and stigma.

It singles out persons with disabilities and mental illness as a specific group of people who are not terminally ill but deserve access to MAID because they have enough suffering to warrant it. Sheer presumption and ignorance. Let’s understand what discrimination is. It is pretending that all Canadians are equal in all ways. We must be equal before the law but we are all dealt different hands by fate and endure practical inequalities of many sorts. The obvious reality is that some of us face profound life challenges (disease, disability, stigma, discrimination, misfortune, poverty, isolation) and require laws that preserve our legal equality within the circumstances of our personal disadvantage. A law that offers death to one group and support and treatment to all others is the paradigm of discrimination.

Bill C-7 pretends to equality by singing a siren song of rights. It says all people with mental illness deserve respect, equal access to MAID, and freedom of choice, all the while ignoring, or even making a mockery of, the particular life realities of living with severe mental illness. This law proclaims that I should consider death instead of recovery. Vulnerable patients need protection from legislators and doctors who want to make it easier for them to die while simultaneously being denied access to universal mental health care. That is the true discrimination.

Myth: Not allowing people with mental illness to access MAID is discriminatory.

Fact: This is a simplistic “equity of access” argument that claims unjustifiable priority over “equality of care” and “health rights”’ and “right to life” arguments.  On its own, it has face value and appeals to our sense of fairness. Understood properly, from the informed and wider vantage point of the real contexts of suffering, it is tragically narrow in focus. It is a defense of simplistic playground rules in a complex world of systemic ableism. It is like saying that everyone in the sandbox deserves toys to play with while ignoring the kids with amputations or in wheelchairs who can’t get into the sandbox.

Myth: MAID is not suicide.

Fact: The Canadian government defines suicide simply and clearly as, “the intentional action of ending one’s life”. MAID is suicide. The American Association of Suicidology does not support the claim that MAID is not suicide, except in the context of terminal illness. Those who claim suicideis impulsive and violent, while MAID is well thought out, peaceful, and dignified, are arbitrarily redefining what suicide is. Social engineering always begins with language engineering. Suicide is taking steps to cause your own death, whatever the steps. 75% of people plan their suicide, and many are completed with care and consideration of the impact on first responders and others. The characterization of all suicides as compelled, impulsive, and violent is factually wrong and perpetuates media stereotypes.

What is clear is that suicide is a raw agony for loved ones. The trappings of medical comfort and the mutual pretense of moral exoneration that the staging of the MAID event promises cannot diminish this sorrow. In fact, it can serve to inflame the wound through the betrayal by both medicine and state.

Myth: MAID doesn’t make patients want suicide.

Fact: Offering MAID interferes with recovery. Clinical relationships are already being profoundly undermined. Some mental health patients are now saying, “Why try to recover when MAID is coming soon and I will be able to choose death?” Some patients keep asking for MAID while they are actually getting better but can’t recognize it yet. A colleague said offering MAID to someone with suicidal thinking is like offering a lethal dose of fentanyl to a person addicted to heroin…it makes no clinical sense at all.

Most suicidal thinking is ambivalent. We must not have legislation that will lead people to death who otherwise would have healed or coped. Offering an easy path to suicide is an ethically indefensible inducement. You can’t offer a sanitized gun in a white coat. Opportunity begets action.

Some say MAID is morally acceptable because the law and a doctor says it is…and it comes with all the idealized trappings of medical comfort along with the relief of guilt that often comes with suicide.  And we know that there is a profound power imbalance that means the very offering of MAID by a doctor carries the message of hopelessness and the clear implication of a recommended course of action…choose death.

Myth: Psychiatrists can predict which people will not recover from their mental illnesses.

Fact: Determining whether a particular psychiatric disease is irremediable is absolutely impossible. We can’t know what is unknowable. People recover after 2 years and after 15 years. People can have improved symptom control and reduced suffering when they get skilled care and treatment. Shared suffering is reduced suffering. Inadequate care causes remediable illnesses to appear irremediable.

Myth: There is good mental health care for all the sickest people in Canada.

Fact: Only 1 in 3 people get help. TMS for treatment-resistant depression is now 90% effective and only funded in 4 provinces. Wait times for all services can be years. Rural Canadians have poor access.

As we speak, 6000 of the sickest people in Ontario are waiting up to 5 years to get specialty psychiatric care. These are degenerative diseases. It is like being diagnosed with a growing brain tumor and having to wait years for chemo while you get sicker and sicker. This is systemic stigmatization and discrimination.

Death versus no treatment is not an autonomous choice. 

Myth: MAID for mental illness enhances personal autonomy.

Fact: All suicide is tragic. When considering suicide people weigh the various means at their disposal. For example, many choose to overdose; others may choose a method that they feel is most acceptable and accessible. Having MAID as an additional option does not actually enhance your autonomy because you can already complete your own suicide plan.

The MAID autonomy claim is analogous to this scenario: I can change the oil on my own car. I may have to check out a YouTube video and buy some tools, and I may get dirty, but as a decisionally capable person I can do it. If the government orders a mechanic to do it for me, my autonomy has not been enhanced. It has simply been made easier to get to the same endpoint. MAID advocates confuse autonomy with facilitation.

MAID advocates claim that not providing such facilitation “compels” people to kill themselves in violent and horrible ways. Who or what is doing the compelling? Many people do kill themselves in very thoughtful and peaceful ways and to claim otherwise is simply to betray ignorance of what actually goes on in the world.

From a suicide prevention perspective, suicide shouldn’t be easy. We have two clear examples (gas in England, poison in Sri Lanka) that show unequivocally that ease of opportunity matters. We know this to be true for farmers with guns and doctors with pills. And soon, thanks to this law, patients with doctors.

Inducement, temptation, bolstering a power imbalance, false moral exoneration, and encouragement to die are not enhancements of autonomy.

Myth: Trying to protect people with mental illness from MAID is discriminating against them by saying they aren’t capable of making their own treatment decisions.

Fact: Everyone agrees that most people living with mental illness are perfectly capable of making their own treatment decisions. Everyone agrees that there are some people who by virtue of illness (e.g. psychosis, depression induced suicidal thinking) can’t make their own reasoned decisions. Where matters are complicated is with people who fall in the middle, people whose decisional capacity is uncertain and who therefore may not be able to provide fully informed consent to an offer of death.Research shows that if 100 psychiatrists assess a person with uncertain decisional capacity, 35 will have one opinion, and 65 will have another. Different psychiatrists have different skill sets and levels of experience. They also have biases like everyone else. As in the Benelux countries, if legalized here, there will be psychiatrists who become the super suicide helpers. Patients will doctor shop until dead.

Myth: We already assess decisional capacity for MAID for physical and mental illness together, so we must be able to do it for mental illness alone.

Fact: What this facile and specious claim (what logic professors call a “categorical fallacy”) tries to gloss over is that all current assessments in Canada are done only with people who are terminally ill. Terminal illness is, in fact, the current legislative condition that allows MAID to be offered. No such necessary condition exists, or has been formulated, for mental illness alone. If the necessary condition posited by MAID advocates for mental illness alone is a subjective claim of “unbearable suffering” then, in fact, the door will be opened to any Canadian seeking MAID for any reason (e.g. grief, tired of life, divorce, abject loneliness) as long as they have some concomitant medical condition that they subjectively and unilaterally validate as distressing enough.

Myth: People who have suffered a lot want MAID.

Fact: No, they want relief of suffering. But they have come to believe that nothing but death will work. Unfortunately, prolonged suffering severely constricts a person’s decision horizon and they stop trying even when good options for healing or reduced suffering are presented to them. In animal research this is called, “learned hopelessness”. 

Ethicists speak of “first and second order desires”. As an example, my first order desire may be to smoke the cigarette I have in my hand, but my second order desire…my more authentic desire…is to stop smoking because I want to preserve my health. With MAID, a person’s first order desire is the immediate relief of suffering, but their second order desire is to heal, to live, and to have a meaningful life.

Myth: MAID is a form of treatment for mental illness.

Fact: Killing someone is never medical treatment. It is a means of eliminating suffering while eliminating the sufferer as well.

Myth: If MAID is legal it must be ethical.

Fact: Just because the law says something is legally allowed doesn’t make it ethically acceptable. Laws have allowed slavery, apartheid, eugenics, forced sterilization, systemic racism, sexism, ableism, and ageism. This law joins a long parade.

Myth: This is about ethics not data.

Fact: It is about both. Evidence-based medicine relies on data. Applied medical ethics uses data to inform the ethical analysis. Unlike most physical diseases, we absolutely lack any prognostic data that can tell us which particular patients with mental illness are likely to get better and which aren’t. There are so many treatment options in psychiatry (along with the passage of time, natural adaptation, learned coping, the alleviation of poverty and loneliness, and the comfort of meaningful relationships) that no studies have been designed that fully capture the complexity of individually unique healing trajectories. For example, having a baby and no longer being suicidal because of a newfound purpose in life are not the types of things commonly studied when looking at diseases. It doesn’t mean we can’t do some form of research, however imperfectly, but we haven’t yet. Proceeding headlong into expanding MAID without such data to inform our ethical and social policy thinking is presumption and fantasy trumping data and reality.

Myth: If a doctor says assisted suicide is morally acceptable then it is.

Fact: What makes any doctor more of a moral expert than your own conscience and learned values. Doctors have been elevated to new age priests but they only have the exact same claim to moral expertise as every other Canadian. A doctor, with all the attendant medical trappings and the halo of perceived goodness, provides false moral absolution and exoneration for a person choosing suicide and using the doctor as the sanitized gun. It is a dance of mutual pretense that does not withstand the scrutiny of ethical analysis. It is a suicide protocol masked by euphemism, false mercy, dissembling, willful casuistry, or naïve self-delusion about the righteousness of one’s path and purpose.

Myth: MAID is consistent with each doctor’s professional obligation to practice according to established standards of care.

Fact: MAID for mental illness makes the doctor a consumer controlled tool of death rather than an expert supporting healing and reducing suffering. Of grave concern is the effort of some legislators to allow MAID for mental illness without any statutory requirement that all standard or reasonable treatments have been tried before the patient is killed. The law as it stands says it is completely up to the person to decide if they are suffering unbearably and they can refuse standard treatments that might help them heal or cope. To allow people to choose death over and above proffered treatments for their illness is an unprecedented undermining of basic medical ethics and a physician’s duty to use their clinical skill and judgment to practice in accord with established standards of care. A doctor cannot support offering death when treatment is untried or incomplete.

Against such an unheard of legislative backdrop, what safeguards can possibly work?

Myth: A doctor helping a patient complete suicide is not a moral issue in a secular and pluralistic society.

Fact: Continuing religious, social, and ethical reflection would not support this claim.  Beliefs and prohibitions about suicide and doctors killing their patients have been held and argued for thousands of years but in our secularized and pluralistic society the media, politicians, and academia often relegate them to the sidelines in the forum of public debate. The disparagement of religious/faith-based perspectives is ironic given that 70% of Canadians report holding faith- or spiritual-based values. Many publicly mask what they privately hold.

All arguments for human dignity and mutual respect are primarily rooted in the religious narratives that historically shaped Canadian law and values. MAID advocates who dismiss objections to their position as being held by “religious people who can’t tell me or society what to do” have profoundly misunderstood and devalued the breadth of serious ethical analysis that underpins traditional religious stances and attendant social structures. I wish I didn’t feel a need to state the obvious, but bigotry is not ethically defensible, nor is it morally acceptable in a pluralistic society.

Conscience rights are actually rooted in what informs our conscience: deep moral intuitions born of faith in something. Many good ethical arguments against physician assisted suicide are rooted not in faith-based or deontological claims but in relational, utilitarian, virtue, and professional ethics. There are many lenses through which we can find common ground and we must have a thoughtful and open discussion of what assisted suicide means for us as ethical (religious or non-religious) persons jointly forging caring societies.

Myth: A psychiatrist killing patients does not violate medical professional ethics.

Fact: The World Medical Association condemns MAID as an extreme violation of medical ethics. The American Psychiatric Association unequivocally condemns MAID for mental illness as an extreme ethical violation. The Canadian Mental Health Association condemns MAID for mental illness. In fact, the long list of medical professional associations that condemn this practice the world over shines a bright light on Canada as an extreme moral outlier if it proceeds down this road. This social juncture is disturbingly reminiscent of the claim to “progressive thinking” that many psychiatrists used to defend eugenics and forced sterilization within my lifetime. It absolutely matters that the world community finds what we are considering morally abhorrent.

Myth: The majority of members of the Canadian Psychiatric Association support MAID for mental illness.

Fact: The Canadian Psychiatric Association has most recently adopted a position of neutrality which supports nothing and everything, and undermines its own credibility by bowing to politics over professional ethics and data. Only 41% of the approximately 5000 Canadian psychiatrists are members of the Canadian Psychiatric Association.

In 2016, the CPA surveyed its membership and 75% of the 500 respondents objected to MAID for mental illness. Without any further survey, or broad or expert consultation, the CPA leadership released a position statement in 2020 that was developed by the 7 member Professional Standards and Practice Committee. It said the CPA supported MAID for mental illness because it was discriminatory to deny any citizen with mental illness equal access to a service other Canadians had available to them. It did not address the ethical or professional duty issues, nor did it consider the lack of evidence for irremediability of psychiatric disorders, nor did it reflect the opinion of the majority of psychiatrists as expressed in 2016, nor did it provide any balanced or considered statement rooted in the clinical expertise of its membership. The CPA openly acknowledged to members it had not even considered whether psychiatric conditions were irremediable, and if so, how that should be assessed. Its leadership chose to make a political statement rather than a statement rooted in a serious consideration of medical ethics, evidence, and the impact of suicide inducement on vulnerable Canadians.

In 2020 the CPA leadership surveyed its members again with what many members have described as a “loaded survey”. They reportedly had only a 23% response rate. The full results of the 10 question survey have still not been released to the membership or the public. Some CPA members report starting the survey but then refusing to complete it because they felt it was so biased. To borrow Noam Chomsky’s phrase, it seemed to be “manufacturing consent”. Any expressed support for the position that a patient should be considered eligible for MAID does nothing to clarify the issues of inadequate data, irremediability, or professional ethics and duty.  And asking whether members support “safeguards” (which of course members would if the practice became legally allowable) doesn’t mean they want it legally allowable in the first place.

The 2020 position statement was quietly modified in 2021 with a very different neutral position which can be found on the CPA website: “There are compelling legal, clinical, ethical, moral and philosophical questions that make this issue particularly challenging. At this time, the CPA has not taken a position on whether MAiD should be available in situations where mental illness is the sole underlying medical condition.” Despite this very different position being posted on the CPA website, the CPA leadership has not prominently announced this neutral stance to policy makers, media and the public, nor did it testify to the significant change at parliamentary hearings.  Instead the CPA has let mistaken public perception of its position stand uncorrected.  Very recent media reports reflect this, including reporting in the national media citing support for MAID for mental illness on grounds that, “The Canadian Psychiatric Association has denounced the exclusion (of mental illness from MAID) as discriminatory, stigmatizing and unconstitutional.”  I will note, psychiatrists are neither judges nor constitutional lawyers.

Attempts by several CPA members to have the issue of MAID and mental illness considered and discussed at the 2020 annual general meeting were thwarted by an arcane procedural objection by the CPA leadership. Despite multiple members requesting a month and a half before the AGM that MAID be added to the agenda, they were told they were too late (of note, at that juncture, the agenda had not been set, and notice for the AGM only went out two weeks later).

A working group was struck to develop a new ‘discussion paper’ on MAID in 2020, many months after the CPA had already released the aforementioned position statement. Some CPA members expressed concern that the new working group membership was weighted with psychiatrists already well known to support MAID for mental illness (including those who had served as expert witnesses for groups advocating for expansion of MAID for mental illness). Of note, membership did not seem to include or welcome experts who have publicly expressed caution regarding the expansion of MAID.

Instead of truly engaging members in response to criticisms, a past president of the CPA (who publicly challenged the actions of the CPA and criticized the lack of engagement in developing the CPA Position Statement, and the lack of evidence and consultation informing CPA’s position) has been repeatedly accused by CPA leadership of ‘misrepresenting’ issues. 

Nearly one full year since the CPA released its Position Statement on MAID without member input, the CPA has still never asked members whether they agree with the 2020 Position Statement or with the CPA’s positioning of the organization in the media on a critical clinical and social issue. Many colleagues are now telling me that they are struggling with whether to resign from the CPA or to enter into a battle with a leadership so far removed from respecting the views of its own membership.

Myth: Most psychiatrists support MAID for Mental Illness.

Fact: Psychiatrists are split over MAID for mental illness. We have little data to establish the degree of the split, but enough data to be certain there is a split. Anyone who claims there is an emerging consensus based on the silence of the majority is simply speculating. Psychiatrists have critical experience and expertise but haven’t been asked any clear questions that reflect complex clinical realities or legislative options. What can be said, as per public statements, is that psychiatrists on both sides of the issue do agree on this: “You can’t predict the course of illness for any individual patient”.

• In a 2016 survey, 500 of 5000 Canadian psychiatrists responded. 75% objected to MAID for mental illness.
• In a recent Quebec survey, 263 of 1300 psychiatrists responded. 36% objected to MAID for mental illness in all circumstances, and 42% said we need at least ten years of treatment before we can consider that further treatment may not produce added benefit.
• Some psychiatrists say this split is about differences in personal values only. Others say it is about professional ethics which should apply to all psychiatrists. A very long list of medical professional associations around the world agree with the latter.
• Some say this is an ethical debate that should be decided by values. Others point out that values are informed by data and that we need to use our scientific and evidence-based methods, however imperfectly, to see what the data shows. Applied ethics uses data. The current data does not support determinations of “irremediability” for mental illnesses (we can’t predict who will or won’t get better over the long term).  
• A few psychiatrists have claimed, “MAID is not suicide”. Others say, “Outside of a terminal context, we can’t practically or conceptually distinguish those seeking MAID for mental illness from those who are suicidal because of their mental illness”.  This latter position is supported by a large body of research and conceptual work from the Canadian and American suicidology associations, and myriad health professional associations.
• A few psychiatrists have said that if someone has subjectively suffered “long enough” we must respect their choice to die and help them to die. Different psychiatrists will have very broad interpretations of when patients have suffered ‘enough’ or had adequate treatment. Others say because it is impossible to predict when suffering may be relieved through treatment, or improved coping, that we have a professional duty to keep trying.

Highlighting these differences shows the split, but the analysis of the values, life stories, clinical experience and acumen, and variance of interpretation of the exact same data are what tell the story. It is complicated. What is not complicated is this. If MAID is allowed for mental illness, we know with 100% certainty that we will make fatal mistakes, and that we will take the lives of patients who would have gotten better…we just won’t know which. The hundreds of people who will die by MAID who would have gotten better are not statistics. If it is your partner, or son, or daughter, do you want a psychiatrist who supports MAID and is legally sanctioned to kill?

Myth: Safeguards will prevent abuses.

Fact: The population of Canada is roughly 37 million people. 50% of all Canadians have, or have had, a mental illness by the age of 40 (19 million people). 44% of Canadians over age 20 have a chronic illness (16 million people). 7 million Canadians have disabilities. Let’s very conservatively estimate that 27 of the 37 million non-terminally ill people in Canada are about to potentially or eventually qualify for MAID when Bill C-7 passes. And there are 92,000 MDs and 6000 NPs, all of whom can induce and complete assisted suicide. How, with those numbers, is it possible to administer and monitor any practical safeguards? Does parliament really intend to swing the door that far open on a so-called “treatment of last resort”?

Some doctors in the Netherlands have stated that if you don’t want physician assisted suicide, you should have your wish written down and make sure your loved ones know, because otherwise it will be assumed you want it. This presumption is a complete and unethical inversion of the long established informed consent protocol: patients are expected to opt-out of doctor assisted death rather than opt-in with clear consent.

Research from Belgium and the Netherlands shows over 30% of doctor caused death (I use the word “caused” not “assisted” because the patients didn’t ask for assistance) went ahead without the consent of the patient (Smets et al, BMJ 2010). 47% of cases of physician caused/assisted death were not reported, despite the legal requirement to do so (this information comes from anonymous surveys of doctors). The reason for non-reporting was most often because consent was not obtained. One such case involved a nun. The treating team felt her lack of request for a physician assisted death was because of her religious values being in the way and so, as an “act of mercy”, they killed her anyway. She didn’t see it coming. About a third of patients don’t. It starts with a sedative in your orange juice and you never wake up.

In Belgium and Netherlands, the requirement that all treatments be tried before causing death was circumvented by doctors who simply chose not to do so, without repercussion. Judges and monitoring bodies simply also ignored the legislated process safeguards. Patients doctor-shopped to find doctors to approve their request for death; one particularly infamous psychiatrist on a public crusade to relieve suffering has become a super suicide helper. To people who say that won’t happen in Canada because we will set up a better and wiser monitoring system, I ask, how is the state going to effectively monitor what goes on behind millions of examining room doors shielded by confidentiality laws?

This is proactive social engineering rather than a response to citizen need, desire or request. Dr. Scott Kim (bioethicist/psychiatrist) makes an important point that the change in Canadian law will bring about a new reality where safeguards fall away in a self-fulfilling manner. It will become the moral norm and expectation that an assisted death be chosen without “medical obstruction”:

“The hope that we can protect psychiatric patients sufficiently by imposing a strict system of safeguards is based on a perspective prior to legalization of psychiatric PAD (physician assisted death). But we fail to note that the legalization itself will likely change the social and practice context of how the safeguards are applied. The very act of legalizing psychiatric PAD provides strong support for it as a social good; this then becomes the context for capacity determinations and the idea of a strict capacity threshold will begin to seem unnecessary, even obstructive. This is not a claim about a slippery slope of abuses and errors; the point is that the very norm of what an abuse or an error means will be recalibrated to the new reality, an apparently reassuring reality with no evidence of abuses and errors.” (Kim S., 2016)

Furthermore, any requirement for X number of years of treatment, or Y number of reasonable treatment trials, or Z number of psychiatric consultations, falters and fails against the backdrop of the unassailable legal principle of the absolute right of treatment refusal, and the Bill C-14 entrenched principle of a subjective claim of unbearable suffering being sufficient. Limiting eligibility over time is impossible in this legal framework. This means that, in practice, proposed safeguards will not be sustainably enforceable.

If we knew there was a clear finish line when treatment in a particular case could be proven to have failed, a safeguard charade wouldn’t matter as much. But there are no such finish lines for mental illnesses. Hence, we can only establish speedbumps but not change any determined person’s ultimate demand for assisted suicide.

A law, that under the weight of its own legal precedent, cannot set any sustainable limit on accessibility to what is supposed to be a rare outcome of last resort is both naïve and dangerous. It means the state has absolutely failed in its duty to protect its citizens.

Validating assisted suicide removes barriers, makes it the norm, and perversely makes caution appear obstructionist.

Myth: Maid for mental illness will have no unintended consequences.

Fact: Today, my patient (in whom psychotic symptoms resolved with medication over the past year) refused my suggestion for psychotherapy as a next step. She said she wants MAID and that “it will soon be legal”, and she doesn’t want psychotherapy because “it might make her change her mind about wanting MAID”. My reason for wanting her to begin psychotherapy is because she has been sick for so long that she now expects to always be sick, and being a “patient in need” has become her established means of eliciting support and care from others. My team can help her move to a healthier position in life where she can better meet her emotional needs. Disturbingly, MAID is, in clinical lingo, “a sick role reinforcement” par excellence. We have to believe we can heal in order to take steps to heal. MAID proffered by a powerful and trusted physician says, “stop hoping”.

In the short term:

• Children who lack life experience and judgement will be allowed to choose this “medical procedure” because it has been falsely labelled as such, rather than what it really is. It is literally an existential choice that should require some expectation of maturity and mastery of life’s challenges. Killing a child absent the opportunity to recover and develop resilience is a gross violation of both parental and state duties to protect. Shockingly, it is already happening in Europe. A twelve year old was allowed to “choose” doctor assisted death.
• More and more healers will abandon their professed vow and become agents of death but retain the now subverted honorific of “Doctor”.  Assisted death will become first line “medical treatment” for the disabled and mentally ill, being offered by hospitals to save money and indoctrinated young doctors blind to their own complicity in a state killing apparatus. Families relieved of their “burden” will be grateful and the media will be full of stories reinforcing the new compassion narrative. Very much like Germany of the 1930’s.
• MAID will mean taking mental illness less seriously. We currently fight stigmatization and want mental illness out in the open and talked about. But with an assisted suicide solution to suffering we move backwards. What will sustain the professional mobilization to research “treatment resistant illness” when it all becomes less urgent. There will be less felt responsibility by some psychiatrists to keep trying no matter what. People will die because MAID also relieves the burden on each psychiatrist to do everything possible, only the patient won’t know that they gave up because their psychiatrist gave up first.

In the long term:

• A new profession of assisted death specialists will emerge. We already have doctors reporting they are personally doing hundreds of MAID “procedures” a year (of note, you don’t need medical training to administer poison). These are the salespeople and emotional advocates who can’t understand why others don’t share their view of the romanticized and sanitized theatres of death. Unfortunately, these medical theatrics seduce and distract from a human reality only understood in the living (and dying) of it.
• We will extinguish the human ecology of suffering. It will no longer to be a human goal to build strength of spirit and character by rising up through suffering.  Finding solutions to living with suffering will simply matter less. We will take lives early to interrupt suffering. It will be snuffed out earlier and earlier so we don’t have to see it, make sense of it, or imagine how we might endure it. Of course you never know what life brings until you get there, but we will normalize exiting the mortal coil before the journey is over. (I will note that our imaginations are almost always worse than any reality.) Suffering will become the great enemy rather than the great teacher. Would Terry Fox have run his Marathon of Hope if MAID had been pressed upon him at his most vulnerable?
• Families and loved ones will be emotional casualties. One of the most beautiful senses of accomplishment in life comes from “doing all I could” and “helping, loving, and comforting to the very end”. They will be denied the choice to support the person they love through a natural death because of the forced sacrifice on the medical altar. Self-sacrifice and love will be falsely twisted into characterizations of selfishness.
• Each person will be made to feel guilty for wanting to use up medical resources, being a burden on their family, and not doing “the right thing”. Medical suicide will become the “normal and expected” path to death. It will be modelled generationally and encouraged through systematic propaganda by a state intent on saving money and eliminating those on the fringe.
• At some point in the future we won’t even have the memory of what it is like now…to be able to hope that more treatment and support could make life better someday. Benjy Freedman, a Montreal bioethicist, may have been prescient in 1994 when he wrote (in response to the Sue Rodrigues case): “…arguments can be made with respect to two other conditions stated by the dissenting Justices: that the request for euthanasia or assisted suicide be firm and unwavering, and that it be provided by a fully informed person of undoubted competence. These conditions are not self-interpreting. They are, moreover, in large degree, social constructions, often understood as relative to accepted or expected choices. What the slippery slope reminds us is that social expectations change over time, under pressure of the previous choice. At present, for example, asking to be killed is an odd choice and might trigger searching questions about competence. Over time, however, this rigour might well give way. It is not hard to envision a time when quite the reverse obtains, when an ill person who fails to ask to be killed is judged to be “in denial” and for that reason in need of therapy.”

Myth: Governments are not motivated to support MAID in order to save money.

Fact: Killing certain citizens saves money. It takes care of the “problem” of the aging population. Palliative care is expensive. MAID pushes the marginalized beyond the final margin once and for all.  How else do you explain the purpose of the recent parliamentary cost analysis of implementing the new law? The government funded study said $150 million would be saved in the first year. If MAID is an essential “Charter right” that must be offered no matter what, why was cost considered? Afterall, it is patently obvious that killing terminally ill people, and disabled people, and mentally ill people, and socially disadvantaged people, sooner than otherwise, saves money. The social engineering agenda appears to be fostering an ethos where people nobly kill themselves so that they are not a burden on others. Additionally, doctors killing such persons is framed as a great act of compassion rather than the commodification of death in a secular age. This is ableism wearing a mask of virtuous hypocrisy.

Conclusion: We cannot know which mental illnesses are irremediable for any given patient. We simply do not have the data necessary to make definitive clinical determinations, despite what some may falsely claim.

Most Canadians are unaware of this artificially pressured legislative push. And only about 10% of psychiatrists have weighed in.  Some of my psychiatrist colleagues are shocked to hear death could be offered without the requirement that at least standard treatments have been tried. They have absolutely no doubt that patients who would have gotten better will die if mental illness is not excluded in Bill C-7. And any proposed procedural safeguards will falter and fail under the weight of individual physicians acting to normalize assisted suicide as a “standard practice” rather than as an option of absolute last resort.

Canada offers MAID but notuniversalpalliative care, disability supports, or mental health care. Do we congratulate ourselves for our compassion in giving people an easier way to die, while depriving them of the resources they need to live? How can Bill C-7 be justified while Canadians’ health rights are ignored and unprotected? Is this what free choice looks like in Canada?

John Maher MD FRCPC

Psychiatrist, Canadian Mental Health Association

President, Ontario Association of ACT & FACT

Editor-in-Chief, Journal of Ethics in Mental Health