Revised March 21, 2021<\/p>\n\n\n\n
Background:<\/strong> As a result of the 2019 Truchon decision in a\nlower court in Quebec, a revised Medical Assistance in Dying (MAID) law (Bill\nC-7) is now being considered by our federal parliament. The proposed\nlegislation removes the \u201cdeath being reasonably foreseeable\u201d requirement and is\nopening the door for physician assisted suicide for people who are not\nterminally ill. <\/p>\n\n\n\n Some persons with mental illness, by virtue of brain disease that often\nincludes symptoms of hopelessness and suicidal thinking, have long been recognized\nas potentially vulnerable to suicide inducement and, until now, have rightfully\nbeen excluded from eligibility for MAID. Suicide prevention is recognized as a\ncritical mental health service necessary to preserve life. The Senate recently\nproposed an amendment that will eliminate this broad protection and allow\nstate-sanctioned suicide for these vulnerable people, starting in 18 months.\nThe Liberals are proposing adding just 6 more months to that time frame. The\nreality is that neither time frame can produce non-existent clinical evidence\nin support of the na\u00efve legal position that doctors can magically predict\nirremediability for mental illness.<\/p>\n\n\n\n Myth:<\/strong> Deciding who will\nget MAID for mental illness will not be a guessing game.<\/strong><\/strong><\/p>\n\n\n\n Fact:<\/strong> The expert panel being constituted by the Liberal\ngovernment can\u2019t manufacture evidence that doesn\u2019t exist in the universe. No\none can know what is unknowable. Everyone can state over and over that some\npeople with mental illness must have irremediable mental illness. But no one\ncan identify precisely who these people are. Not you. Not any experienced\npsychiatrist. Unless they guess. Or unless they mean by irremediable that\nsomeone hasn\u2019t gotten better when their suffering is considered at a certain\npoint in time (as would be true of everyone at given points). What point in\ntime? During the year they are waiting for psychiatry services? During the 5\nyears they are waiting for sub-specialty psychiatry care? During the endless\namount of time they are waiting for non-existent intensive case management? Or\na place to live? During the time they are waiting for the standard treatment\nthat the government hasn\u2019t funded? During the time disease induced hopelessness\nhas kept them from seeking help? During the time their disease has impaired\ntheir insight into the fact they need help? Start the timer!<\/p>\n\n\n\n How many die by suicide while waiting for months or\nyears for any mental health services?<\/p>\n\n\n\n How many die by suicide after being discharged\nprematurely from in-patient psychiatry?<\/p>\n\n\n\n How many die by suicide because they are unwilling to\ngo to the ER and be treated with disrespect and disdain again?<\/p>\n\n\n\n How many die by suicide because they are labelled a\n\u201cdrug seeking problem\u201d?<\/p>\n\n\n\n How many die by suicide after being sent home from the\nEmergency Room?<\/p>\n\n\n\n How many die by suicide because of suffering wrought\nby abject loneliness?<\/p>\n\n\n\n How many die by suicide because of the suffering\nwrought by poverty?<\/p>\n\n\n\n How many die by suicide because of stigmatization and\nsocial rejection?<\/p>\n\n\n\n How many die by suicide because of homelessness?<\/p>\n\n\n\n How many die by suicide because their families can no\nlonger cope with their symptoms?<\/p>\n\n\n\n How many die by suicide because they saw a story about\nsuicide in the media?<\/p>\n\n\n\n How many die by suicide because of inexperienced\ndoctors?<\/p>\n\n\n\n How many die by suicide because of misdiagnosis? <\/p>\n\n\n\n How many die by suicide because their doctor doesn\u2019t\nseek advice from sub-specialist colleagues?<\/p>\n\n\n\n How many die by suicide because they live in a rural\ncommunity and have inadequate treatment?<\/p>\n\n\n\n How many die by suicide because of the psychiatrist\nshortage? (over 200 positions unfilled at hospitals in Ontario)<\/p>\n\n\n\n How many die by suicide because of poor treatment by\ntheir own doctor who has internalized the same stigmatization and judgement of\nother Canadians?<\/p>\n\n\n\n How many die by suicide because they feel their life\njust doesn\u2019t matter to anyone?<\/p>\n\n\n\n How many will refuse treatment because MAID will be a\nfaster, easier, doctor-supported alternative to healing?<\/p>\n\n\n\n How many will die by MAID who could live a good, long\nlife instead?<\/p>\n\n\n\n You don\u2019t know\nthe answer to these questions? Neither do I. Neither will the members of the\nexpert panel being set up to give our country the \u201cMAID for Mental Illness\nHow-to Manual\u201d. But that won\u2019t stop them from writing the rules for the\nguessing game as though they do. Let\u2019s play the odds they will say. If you have\nsuffered a long time and tried some treatments that is good enough. It won\u2019t\nmatter whether it was provided in time to prevent brain damage from your\ndegenerative disease, or the right treatment even, or whether your suffering\nwas because of poverty or loneliness or homelessness, or whether you kept\nrefusing treatment offered. It won\u2019t matter because wrong guesses won\u2019t be\nexposed from the grave. <\/p>\n\n\n\n \u201cCanada, the\nGuessing Game Capital of the World\u201d<\/p>\n\n\n\n Myth:<\/strong> The Justice\nMinister\/Attorney General of Canada didn\u2019t mislead Canadians.<\/strong><\/strong><\/p>\n\n\n\n Fact:<\/strong> One of the most extraordinary things about the last\nfew months in the flow of events that led to the House of Commons passing Bill\nC-7 (by a vote of 180-149) on March 11, 2021 was that an Attorney General of\nCanada, David Lametti, sworn to uphold the laws of the land, and his\nParliamentary Secretary, MP Arif Virani, repeatedly made statements that were\nclearly misleading. And then other Liberals repeated them over and over in their\nwritten and verbal \u201ctalking points\u201d. <\/p>\n\n\n\n In November,\nparliament and the small group of Canadians that were even aware of what was\nhappening (what with a pandemic on our minds) were told three things:<\/p>\n\n\n\n In February, when\nexamining the bill, the Senate made up completely new legislation and added\nMAID for mental illness to begin in 18 months. The bill went back to the House\nof Commons where the Liberals accepted the new legislation (and said 24 months\nto implementation instead of 18.) They said a year to study ways to implement\nit (implementation being a foregone conclusion) and then the second year to\noperationalize it. <\/p>\n\n\n\n What is\nremarkable, as all other political parties except the Bloc decried, is that:<\/p>\n\n\n\n And\nso, in contrast to just a few months ago, the Attorney General of Canada is now\nsaying:<\/p>\n\n\n\n When did this\nmagical consensus appear? When did the specific consultations on this new law\noccur? In fact they didn\u2019t. The\ntestimony heard previously was never in relation to the new law. It couldn\u2019t\nhave been because the new law didn\u2019t exist! The previous testimony was from\nhundreds of disability organizations. Their testimony was ignored. For mental\nillness the Liberals just skipped a step and didn\u2019t even have to pretend they\nlistened.<\/p>\n\n\n\n The Prime\nMinister has said over and over during COVID that the government follows the\nadvice of experts and the science. They didn\u2019t in this case. They didn\u2019t even\nask us.<\/p>\n\n\n\n A couple of years\nago the Canadian Council of Academies advised against MAID for mental illness.\nCAMH, CMHA, and myriad mental health organizations are already on record as\nbeing against it. On March 11, when a Conservative MP in the House of Commons\nsaid he held a letter with 129 organizations objecting, and he asked MP Arif\nVirani (Minister of Justice spokesperson) to name even one organization that\nsupported the new law, MP Virani was at an obvious loss and then suggested\nmaybe a Quebec psychiatrist group (who by their own admission report their\npsychiatrists are extremely split) and that Dying with Dignity is in support.\nDying with Dignity! A suicide lobby group is what this government offers as\nsupport for legislation that facilitates suicide! Utterly shameful!<\/p>\n\n\n\n Will the\ngovernment stack the expert panel it is creating as it follows through on the\ncharade of safeguards? It would seem it has to, because an otherwise balanced\ngroup of experts that understands clinical realities and the science would\nrecommend that the law cannot be implemented because mental illness can never\nmeet the Bill C-7 legal test of irremediability. <\/p>\n\n\n\n Every Canadian\nwith a disability and every Canadian touched by a personal experience with\nmental illness should remember this moment at the ballot box. I wonder if the\nLiberals and Bloc have registered just how many tens of millions of Canadians\nthat actually is?<\/p>\n\n\n\n Myth:<\/strong> Members of Parliament are doing their duty\nas legislators by complying with the Charter of Rights.<\/strong><\/strong><\/p>\n\n\n\n Fact:<\/strong> That is only part of their duty. If the\nCharter said slavery or eugenics or forced sterilization were the law of the\nland (all of which have been the case on Canadian soil) MPs duty in the present\nday would clearly not be to blindly comply with a particular Charter\ninterpretation but rather ensure justice and equality for all. The Charter is a\nliving document subject to judicial interpretation and embodied in just\nlegislation made by just legislators. A presumed and untested interpretation of\nthe Charter mustn\u2019t lead to the abrogation of legislative duty, thoroughness,\nreflection, and ultimate responsibility to protect all citizens. MPs marching\nin lockstep in response to Truchon, the Senate amendment, and claims to\ncertainty about the primacy of a particular charter interpretation are all\nexamples of the tail wagging the dog and the dog letting it.<\/p>\n\n\n\n Myth:<\/strong> The 24 month\n\u201csunset clause\u201d is a reasonable way to ensure that MAID for mental illness goes\nahead safely.<\/strong><\/p>\n\n\n\n Fact:<\/strong> This\nshould properly be called the \u201cdelayed implementation clause\u201d. Approving the 24\nmonth sunset clause is absolutely tantamount in this present moment to saying\nwe already know it must <\/strong>be allowed even though we don\u2019t have any present\nevidence that it should<\/strong> be allowed. The legal argument must follow from\nclinical evidence, and not vice versa. Pretending doctors can do something they\ncan\u2019t in order to bolster a legal position is the false manufacturing of\nevidence. If evidence in support of clear clinical prognostication\nexisted for these particular brain diseases it would have already come forth\nthrough the Canadian Council of Academies exhaustive review, and it would have\nbeen loudly confirmed by MAID expansionists. Yet, not one of them actually said\nwe can predict irremediability in any particular patient. They keep saying,\nlike a mantra, that \u201cpeople with irremediable mental illness deserve MAID\u201d.\nBut they have no data, and no clinical evidence-based means, to identify who\nthese individuals might actually be. Extensive clinical experience tells us\nthat such patients are rare or may not exist except insofar as there are\npatients who refuse potentially effective treatments and the myriad options for\nthe relief of suffering (the case of EF is a case in point). What ethical\ndoctor would use guesswork when the outcome is certain death? Unfortunately,\nthere are inexperienced psychiatrists, and there will be psychiatrists who are\nconfident with guesswork because no one will ever know if they were wrong. Do\nwe really want legislation that suborns incompetent professional practice?<\/p>\n\n\n\n It comes down to this: Let\u2019s\nagree there are people with irremediable mental illness. Who are they? Your\nuntrained guess is as good as any<\/strong> psychiatrist. That should worry you.<\/p>\n\n\n\n Myth: It must be a doctor who performs the\nassisted death procedure because it is a medical act.<\/strong><\/p>\n\n\n\n Fact: <\/strong>If it is a medical act why is it viewed and\noperationalized in the United States and Switzerland as a social freedom or\nautonomous act of citizenship? In those countries it is not a health care\nintervention, treatment procedure, or part of the medicalized tableau it has\nbecome in Canada. In those countries people take the poison pill on their own\ntime, in their own location of choice, and with whomever they wish. In those\ncountries you have to meet certain criteria (e.g. terminally ill) to get the\npoison pill from your doctor, but after that you are on your own. If you can complete\nyour suicide without a doctor is it still a medical act?<\/p>\n\n\n\n In the US it is illegal to\ninject the poison to cause death (the person has to take it in pill form) but\nin Canada that is the preferred method used by 97% of \u201cMAID providers\u201d to date.\nIf the person is in hospital, very near death, can\u2019t swallow, already has an IV\nline in, I get the practical logic of it. But if you have mental illness and\ncan do it yourself whenever you want, absent medical involvement, what does\nthat tell us about the act itself?<\/p>\n\n\n\n MAID providers say you need\nsomeone who can start an IV line\u2026that makes it medical! So anyone who draws\nblood in a lab can also do it? So anyone addicted to IV morphine or heroin or\ncrack can also do it? So anyone who has a one hour how-to training session can\nalso do it? So any Dying with Dignity volunteer who wants to get good at it can\ndo it? Like getting my Red Cross Death-Aid certificate? <\/p>\n\n\n\n MAID providers say over and\nover that an IV method causes death faster. I am not sure why 3 hours is better\nthan 7 hours at that point. \u201cEasier on people watching\u201d, they say. Do they\nreally believe that a few hours will in any way assuage the agony of a\nphysically healthy loved one choosing suicide? They also say the person might\nthrow up the pill\u2026again they are talking about people on the cusp of death who\nare severely physically ill\u2026not a relevant consideration in people with mental\nillness who are physically able to swallow. Besides, if you throw up, take\nanother pill. The do-it yourself kits can have two pills and a checklist for\ndocuments to sign attesting it was uncoerced suicide.<\/p>\n\n\n\n MAID providers say how\nsupportive and comforting and essential the doctor\u2019s and nurse\u2019s presence are.\nBut, again, this is in the context of terminal illness. In the suicide context?\nDo they help by providing false moral absolution for the person and exoneration\nfor themselves and family members? Do people really believe the psychological\ndynamics are this simplistic? The Swiss experience confirms substantial\ntraumatization for a lot of loved ones. In a non-terminal context these are not\nthe sweet goodbyes that MAID expansionists fantasize they are.<\/p>\n\n\n\n Myth: \u201cReasonably forseeable death\u201d should not be a necessary\ncondition for MAID.<\/strong><\/p>\n\n\n\n Fact: <\/strong> The MAID law from 2016 (Bill C-14) provides access to MAID\nfor people who have a “grievous and irremediable medical condition.”\nThe term is specified under the law as having the following components: 1) \u201ca\nserious and incurable illness, disease or disability\u201d; 2) \u201can advanced state of\nirreversible decline of capabilities\u201d; 3) which causes \u201cunbearable physical or\npsychological suffering that cannot be relieved under conditions that the person considers acceptable<\/strong>\u201d\nand; 4) \u201cthe person\u2019s natural death has become reasonably foreseeable, taking\ninto account all medical circumstances, and not requiring a specific prognosis\nas to how long they have left to live.\u201d <\/p>\n\n\n\n All these conditions have needed to be fulfilled for\nMAID to proceed, and thereby limited MAID to the context of terminal illness.\nEthicists speak of necessary and sufficient conditions for a course of action\nto be justifiable. By removing the \u201cdeath being reasonably forseeable\u201d\ncriterion, the judge in Truchon made a unilateral determination that terminal\nillness was not a necessary condition for MAID and made the other conditions\njointly sufficient. What logic supports making just that particular necessary\ncondition unnecessary? Some would argue that it is not just necessary but also\nhas primacy of importance in any weighting of the four conditions. \u201cIf you are\ndying, what does it matter if you die a few weeks earlier?\u201d \u201cIf you are dying\nsoon, that will stop the suffering.\u201d \u201cWhat does it matter if your disease is\nremediable (not curable but your suffering can be reduced) if you are going to\ndie in a few weeks anyway?\u201d <\/p>\n\n\n\n On one interpretation, the\nlogic in Truchon is akin to saying that every Canadian should have access to\nchemotherapy even if you don\u2019t have cancer, or that every Canadian should have\naccess to a wheelchair even if you have no problem walking. Having a\nterminal illness with very little time left to live is in fact a particular\nphysical state that entails multiple ethical, conceptual, and pragmatic\nconsiderations that are both particular and unique to it. The current MAID\ndebate and the 50 years of medical ethics literature on euthanasia attest to\nthe different moral and empirical status of the near death context. <\/p>\n\n\n\n Myth:<\/strong> MAID for terminal\nillness is the same as MAID for mental illness.<\/strong><\/p>\n\n\n\n Fact:<\/strong> Terminal\nillness means sure death and no hope. Mental illness means no death and\nsustaining hope. Profoundly different states of being. Saying the two are the\nsame for purposes of assisted death is twisting logic in the service of\nideology. <\/p>\n\n\n\n With the \u201creasonably\nforseeable death\u201d criterion removed in Bill C-7, the use of the\n\u201cirremediability\u201d criterion is being changed in practice from definitely <\/strong>irremediable to possibly <\/strong>irremediable. Is \u201cpossibly\u201d\ngood enough when what is at stake is not 6 months but 60 years?<\/p>\n\n\n\n Some people extrapolate\nfrom the \u201cbeautiful stories about warm goodbyes\u201d with MAID for terminal illness\nto a claim that the same will hold true outside the terminal context. On\nthe contrary, the Swiss, Belgian and Dutch experience shows the non-terminal\ncontext is fraught with distress (families don\u2019t support the death, families\nwill not participate, families initiate legal action, families still have hope\nof recovery, families feel abandoned, family members are traumatized –\nincluding PTSD).<\/p>\n\n\n\n Myth: There is no distinction between physical\nand mental Illness when it comes to MAID.<\/strong><\/strong><\/p>\n\n\n\n Fact:<\/strong> There are brain diseases that are in the clearly\ndefined domain of psychiatric disorders. Physiologically there is of course a\ncontinuum\u2026we have one whole body. And suffering is suffering. However,\ndiagnostically and categorically there is not one continuum. There are 3\ntreatment categories: physical illness, mental illness, and mixed illness. <\/p>\n\n\n\n Mixed illness includes dementias (e.g. Alzheimers) and certain\nneurological disorders (e.g Huntington\u2019s) that can meet criteria for terminal\ndisorders. <\/p>\n\n\n\n Clear mental illness is distinguished by the brain diseases that cause\npsychiatric symptoms: suicidal thinking, abnormal mood, impaired cognition,\npsychosis, hopelessness\u2026a very specific list of symptoms and symptom clusters.\nThey are not terminal conditions.<\/p>\n\n\n\n Here is another way of telling the difference. With physical illnesses I\nknow when treatment attempts are exhausted, and I make that determination in a\nmedical milieu free of societal stigma. With mental illness:<\/p>\n\n\n\n Myth: The Senate supported an 18 month \u201csunset\nclause\u201d because they wisely weighed all of the evidence they heard.<\/strong><\/p>\n\n\n\n Fact: <\/strong>The preponderance of recent Senate Committee evidence\ndid not support moving forward with MAID for mental illness (hence the\nCommittee\u2019s very thoughtful report). A key issue is the question of\nestablishing whether some mental illnesses can meet the legal test of\nirremediability. Either there is adequate data to support determinations of\nirremediability or there is not. If it existed it would have been presented. It\ndoes not exist, so it could not be presented. The Committee heard and seemingly\nunderstood this. However, in ignoring the Committee report, the majority of\nmembers in the full Senate gave unjustified weight to supposition, fallacious\nreasoning, and\/or a political agenda. Furthermore, they are trying to pre-empt the\nmandated (and COVID delayed) legislative review of Bill C-14; they did not weigh\nthe clear recommendation of the Canadian Council of Academies that advised\nagainst proceeding with MAID for mental illness due to lack of data and the\nlimits of clinical prognostication; they did not respect the informed pleas of\nmyriad disability and mental health organizations representing the most\nvulnerable of citizens; they ignored the grave concerns of Indigenous peoples\nand the United Nations; and they are trying to bind parliament to a course of\naction of their own desire with no request for a reference to the Supreme\nCourt. <\/p>\n\n\n\n New information or better reasoning will not\nmiraculously appear in the next 18 months. The Senate has made us an outlier in\nthe world. This is not about social progress, or recognition of a changing\nworld and citizen values. The Senate is ignoring the evidence and sound reasoning\nput before it. Martin Luther King said his task was to help people see the injustice\nbefore their very eyes. I expected better from the senators. I needed better. I\ncan tell you today the names of my patients who will die because of their\nactions\u2026.patients who are gradually healing but plan to stop trying.<\/p>\n\n\n\n Every Canadian citizen already has the right\nto kill him or herself. MAID for mental illness does not add any new legal\nliberty and there is no legal \u201cright to death\u201d in our charter. <\/p>\n\n\n\n Of the 100% of\nCanadians who attempt suicide, only 23% try again, and only 7% complete\nsuicide. MAID\nfor mental illness only serves to make suicide easier. Why does the Senate want\nsuicide to be easier? The Senate has failed in its duty to protect.<\/p>\n\n\n\n Myth: \u201cBill C-7 must be passed right away because suffering\nCanadians need relief through MAID as fast as possible!\u201d<\/strong><\/p>\n\n\n\n Fact: <\/strong>If this is true,\nthen it is also true that universal palliative care must be available as fast\nas possible, and that universal disability supports must be available as fast\nas possible, and that universal mental health care must be available as fast as\npossible, because it is the absence of these that is making some people suffer\nso much that they want to die rather than live. Why do some people with the\npower to rectify longstanding discrimination wear a cloak of virtue to hide\ntheir disfigured sense of decency?<\/p>\n\n\n\n We can all agree\nthat terrible suffering must be responded to with haste and compassion. Why is\nit, though, that the many decades of extreme suffering of persons with\ndisabilities and mental illness did not garner this same politically urgent\nresponse? Why the focus on MAID and the political pretense that Bill C-7 is the\nmost urgent and best solution? Why was Truchon not appealed to the Supreme\nCourt? <\/p>\n\n\n\n If it weren\u2019t for\nthe COVID pandemic and winter weather Parliament Hill would see the largest\nprotest of Canadians in wheelchairs ever assembled. If it weren\u2019t for poverty\nand marginalization and the fact most Canadians are unaware of this shocking\npush for state sanctioned suicide, those protesters would be joined by millions\nmore.<\/p>\n\n\n\n Who do you stand\nwith Liberal Party? You proclaim loudly that you stand with Indigenous peoples\nbut they are telling you this bill that pretends to equality is colonialism in\nsheep\u2019s clothing. They are saying that this law will kill them in a medical\nsystem that is already unabashedly racist. It is another imposition of colonial\nvalues being used to crush Indigenous spirituality and mock respect for the\nsacredness of life.<\/p>\n\n\n\n Who do you stand\nwith NDP Party? You say with the poor and vulnerable\u2026are you pretending not to\nhear? The disability organizations are shouting loudly into your face. <\/p>\n\n\n\n Who do you stand\nwith Conservative Party? The mentally ill need your help and protection, not\nthe false mercy of state killing.<\/p>\n\n\n\n This \u201cothering\u201d,\nthis heartless stigmatization, this inability to bridge the gulf of ableism,\nthis lack of understanding at the deepest level of our shared humanity, is\nobvious to those watching from across the gulf\u2026 from our wheelchairs and\nhomeless shelters\u2026from our homes that look so placid to passersby but are in\nreality places of secret sorrow and struggle and hopelessness. What utter\ntragedy that people in power spouting sham slogans don\u2019t even know what they\ndon\u2019t know. Blind with eyes wide\nopen. <\/p>\n\n\n\n Myth:<\/strong> People deserve death\nwith dignity and MAID provides that.<\/strong><\/p>\n\n\n\n Fact:<\/strong> This debate has distorted\nwhat dignity means. Dignity means deserving of honour or respect. What MAID\nadvocates mean by loss of dignity is loss of control, loss of superficial\nappearance, and self-critical judgement. They have, tragically, subverted the\nmost dignified acts of all: unfailing love and deep respect for each other in\nall life circumstances. Bathing my dying grandmother, whispered conversations\non the threshold of separation, silent reflection and presence through a long\nnight waiting for a last breath\u2026these are the moments of greatest dignity.<\/strong><\/p>\n\n\n\n Dignity is found within\nour relationships. It is about whether someone looks at you and treats you with\nrespect rather than with subtle disdain or prejudice, or makes you feel like\nyou are bothering them. Dignity is not about the means of death. Dying with\ndignity means dying in a milieu of care, love, kindness and respect. Anyone who\nsays all of these things are not present in a natural death setting simply does\nnot understand what dignity is.<\/p>\n\n\n\n Myth: Bill C-7 is not discriminatory.<\/strong><\/p>\n\n\n\n Fact: <\/strong>Canadian disability organizations, mental health\norganizations, Indigenous organizations, religious organizations, and the\nUnited Nations all say Bill C-7 is absolutely discriminatory because it singles\nout vulnerable Canadians and offers them the inducement of physician assisted\ndeath without offering adequate disability supports or treatment to help them\nlive full lives free of the suffering caused by poor health care, poverty, and\nstigma.<\/p>\n\n\n\n It singles out persons with disabilities and\nmental illness as a specific group of people who are not terminally ill but\ndeserve access to MAID because they have enough suffering to warrant it. Sheer\npresumption and ignorance. Let\u2019s understand what discrimination is. It is\npretending that all Canadians are equal in all ways. We must be equal before\nthe law but we are all dealt different hands by fate and endure practical\ninequalities of many sorts. The obvious reality is that some of us face\nprofound life challenges (disease, disability, stigma, discrimination,\nmisfortune, poverty, isolation) and require laws that preserve our legal\nequality within the circumstances of our personal disadvantage. A law that\noffers death to one group and support and treatment to all others is the\nparadigm of discrimination.<\/p>\n\n\n\n Bill C-7 pretends to equality by singing a\nsiren song of rights. It says all people with mental illness deserve respect,\nequal access to MAID, and freedom of choice, all the while ignoring, or even\nmaking a mockery of, the particular life realities of living with severe mental\nillness. This law proclaims that I should consider death instead of recovery. Vulnerable patients need\nprotection from legislators and doctors who want to make it easier for them to\ndie while simultaneously being denied access to universal mental health care.\nThat is the true discrimination. <\/p>\n\n\n\n Myth: Not allowing people with mental illness to\naccess MAID is discriminatory.<\/strong><\/p>\n\n\n\n Fact:<\/strong> This is a simplistic \u201cequity of access\u201d argument\nthat claims unjustifiable priority over \u201cequality of care\u201d and \u201chealth rights\u201d\u2019\nand \u201cright to life\u201d arguments. On its\nown, it has face value and appeals to our sense of fairness. Understood properly,\nfrom the informed and wider vantage point of the real contexts of suffering, it\nis tragically narrow in focus. It is a defense of simplistic playground rules\nin a complex world of systemic ableism. It is like saying that everyone in the\nsandbox deserves toys to play with while ignoring the kids with amputations or\nin wheelchairs who can\u2019t get into the sandbox.<\/p>\n\n\n\n Myth: MAID is not suicide.<\/strong><\/p>\n\n\n\n Fact:<\/strong> The Canadian government defines suicide\nsimply and clearly as, \u201cthe intentional action of ending\none\u2019s life\u201d. MAID\nis suicide. The\nAmerican Association of Suicidology does not support the claim that MAID is not\nsuicide, except in the context of terminal illness. Those\nwho claim suicideis impulsive and\nviolent, while MAID is well thought out, peaceful, and dignified, are\narbitrarily redefining what suicide is. Social engineering always begins with\nlanguage engineering. Suicide is taking steps to cause your own death, whatever\nthe steps. 75% of people plan their suicide, and many are completed with care\nand consideration of the impact on first responders and others. The\ncharacterization of all suicides as compelled, impulsive, and violent is\nfactually wrong and perpetuates media stereotypes.<\/p>\n\n\n\n What is clear is that\nsuicide is a raw agony for loved ones. The trappings of medical comfort and the\nmutual pretense of moral exoneration that the staging of the MAID event\npromises cannot diminish this sorrow. In fact, it can serve to inflame the\nwound through the betrayal by both medicine and state.<\/p>\n\n\n\n Myth:\nMAID doesn\u2019t make patients want suicide.<\/strong><\/p>\n\n\n\n Fact:<\/strong>\nOffering MAID interferes with recovery. Clinical relationships are already\nbeing profoundly undermined. Some mental health patients are now saying, \u201cWhy\ntry to recover when MAID is coming soon and I will be able to choose death?\u201d\nSome patients keep asking for MAID while they are actually getting better but\ncan\u2019t recognize it yet. A colleague said offering MAID to someone with suicidal\nthinking is like offering a lethal dose of fentanyl to a person addicted to\nheroin\u2026it makes no clinical sense at all.<\/p>\n\n\n\n Most suicidal thinking\nis ambivalent. We must not have legislation that will lead people to death who\notherwise would have healed or coped. Offering an easy path to suicide is an ethically indefensible\ninducement. You can\u2019t offer a sanitized gun in a white coat.\nOpportunity begets action.<\/p>\n\n\n\n Some say MAID is\nmorally acceptable because the law and a doctor says it is…and it comes with\nall the idealized trappings of medical comfort along with the relief of guilt\nthat often comes with suicide. And we\nknow that there is a profound power imbalance that means the very offering of\nMAID by a doctor carries the message of hopelessness and the clear implication\nof a recommended course of action\u2026choose death.<\/p>\n\n\n\n Myth:<\/strong> Psychiatrists can predict which people will\nnot recover from their mental illnesses.<\/strong><\/p>\n\n\n\n Fact:<\/strong> Determining\nwhether a particular psychiatric disease is irremediable is absolutely impossible.\nWe\ncan\u2019t know what is unknowable. People recover after 2\nyears and after 15 years. People can have improved symptom control and reduced\nsuffering when they get skilled care and treatment. Shared suffering is reduced\nsuffering. Inadequate care causes remediable illnesses to appear irremediable.<\/p>\n\n\n\n Myth: There is good mental health care for all\nthe sickest people in Canada.<\/strong><\/p>\n\n\n\n Fact:<\/strong> Only\n1 in 3 people get help. TMS for treatment-resistant depression is now 90%\neffective and only funded in 4 provinces. Wait times for all services can be\nyears. Rural Canadians have poor access. <\/p>\n\n\n\n As we speak, 6000 of\nthe sickest people in Ontario are waiting up to 5 years to get specialty psychiatric\ncare. These are degenerative diseases. It is like being diagnosed with a\ngrowing brain tumor and having to wait years for chemo while you get sicker and\nsicker. This is systemic stigmatization and discrimination. <\/p>\n\n\n\n Death versus no\ntreatment is not an autonomous choice. <\/p>\n\n\n\n Myth: MAID for mental illness enhances personal\nautonomy.<\/strong><\/p>\n\n\n\n Fact: <\/strong>All suicide is tragic. When considering suicide\npeople weigh the various means at their disposal. For example, many choose to\noverdose; others may choose a method that they feel is most acceptable and\naccessible. Having MAID as an additional option does not actually enhance your\nautonomy because you can already complete your own suicide plan.<\/p>\n\n\n\n The MAID autonomy claim is analogous to this\nscenario: I can change the oil on my own car. I may have to check out a YouTube\nvideo and buy some tools, and I may get dirty, but as a decisionally capable\nperson I can do it. If the government orders a mechanic to do it for me, my\nautonomy has not been enhanced. It has simply been made easier to get to the\nsame endpoint. MAID advocates confuse autonomy with facilitation.<\/p>\n\n\n\n MAID advocates claim that not providing such\nfacilitation \u201ccompels\u201d people to kill themselves in violent and horrible ways.\nWho or what is doing the compelling? Many people do kill themselves in very\nthoughtful and peaceful ways and to claim otherwise is simply to betray\nignorance of what actually goes on in the world.<\/p>\n\n\n\n From\na suicide prevention perspective, suicide shouldn\u2019t be easy. We have two clear examples\n(gas in England, poison in Sri Lanka) that show unequivocally that ease of\nopportunity matters. We know this to be true for farmers with guns and doctors with\npills. And soon, thanks to this law, patients with doctors.<\/p>\n\n\n\n Inducement,\ntemptation, bolstering a power imbalance, false moral exoneration, and\nencouragement to die are not enhancements of autonomy.<\/p>\n\n\n\n Myth: Trying to protect people with mental\nillness from MAID is discriminating against them by saying they aren\u2019t capable\nof making their own treatment decisions.<\/strong><\/p>\n\n\n\n Fact: <\/strong>Everyone agrees that most people living with\nmental illness are perfectly capable of making their own treatment decisions.\nEveryone agrees that there are some people who by virtue of illness (e.g.\npsychosis, depression induced suicidal thinking) can\u2019t make their own reasoned\ndecisions. Where matters are complicated is with people who fall in the middle,\npeople whose decisional capacity is uncertain and who therefore may not be able\nto provide fully informed consent to an offer of death.Research shows that if 100\npsychiatrists assess a person with uncertain decisional capacity, 35 will have\none opinion, and 65 will have another. Different\npsychiatrists have different skill sets and levels of experience. They also\nhave biases like everyone else. As in the Benelux countries, if legalized here,\nthere will be psychiatrists who become the super suicide helpers. Patients will\ndoctor shop until dead.<\/p>\n\n\n\n Myth: We already assess decisional capacity for\nMAID for physical and mental illness together, so we must be able to do it for\nmental illness alone.<\/strong><\/p>\n\n\n\n Fact: <\/strong>What this facile and specious claim (what logic\nprofessors call a \u201ccategorical fallacy\u201d) tries to gloss over is that all\ncurrent assessments in Canada are done only with people who are terminally ill.\nTerminal illness is, in fact, the current legislative condition that allows\nMAID to be offered. No such necessary condition exists, or has been formulated,\nfor mental illness alone. If the necessary condition posited by MAID advocates for\nmental illness alone is a subjective claim of \u201cunbearable suffering\u201d then, in\nfact, the door will be opened to any Canadian seeking MAID for any reason (e.g.\ngrief, tired of life, divorce, abject loneliness) as long as they have some\nconcomitant medical condition that they subjectively and unilaterally validate\nas distressing enough.<\/p>\n\n\n\n Myth: People who have suffered a lot want MAID.<\/strong><\/p>\n\n\n\n Fact: <\/strong>No, they want relief of suffering. But they have\ncome to believe that nothing but death will work. Unfortunately, prolonged\nsuffering severely constricts a person\u2019s decision horizon and they stop trying\neven when good options for healing or reduced suffering are presented to them.\nIn animal research this is called, \u201clearned hopelessness\u201d. <\/p>\n\n\n\n Ethicists speak of \u201cfirst and second order\ndesires\u201d. As an example, my first order desire may be to smoke the cigarette I\nhave in my hand, but my second order desire\u2026my more authentic desire\u2026is to stop\nsmoking because I want to preserve my health. With MAID, a person\u2019s first order\ndesire is the immediate relief of suffering, but their second order desire is\nto heal, to live, and to have a meaningful life.<\/p>\n\n\n\n Myth: MAID is a form of treatment for mental\nillness.<\/strong><\/p>\n\n\n\n Fact: <\/strong>Killing someone is never medical treatment. It is a\nmeans of eliminating suffering while eliminating the sufferer as well.<\/p>\n\n\n\n Myth: If MAID is legal it must be ethical.<\/strong><\/p>\n\n\n\n Fact: <\/strong>Just because the law says something is legally\nallowed doesn\u2019t make it ethically acceptable. Laws have allowed slavery,\napartheid, eugenics, forced sterilization, systemic racism, sexism, ableism, and\nageism. This law joins a long parade.<\/strong><\/p>\n\n\n\n Myth:<\/strong> This is about ethics not\ndata.<\/strong><\/p>\n\n\n\n Fact:<\/strong> It is about both. Evidence-based medicine\nrelies on data. Applied medical ethics uses data to inform the ethical\nanalysis. Unlike most physical diseases, we absolutely lack any prognostic data\nthat can tell us which particular patients with mental illness are likely to\nget better and which aren\u2019t. There are so many treatment options in psychiatry\n(along with the passage of time, natural adaptation, learned coping, the\nalleviation of poverty and loneliness, and the comfort of meaningful\nrelationships)\nthat no studies have been designed that fully capture the complexity of\nindividually unique healing trajectories. For example, having a baby and no\nlonger being suicidal because of a newfound purpose in life are not the types\nof things commonly studied when looking at diseases. It doesn\u2019t mean we can\u2019t\ndo some form of research, however imperfectly, but we haven\u2019t yet. Proceeding\nheadlong into expanding MAID without such data to inform our ethical and social\npolicy thinking is presumption and fantasy trumping data and reality. <\/p>\n\n\n\n Myth: If a doctor says assisted suicide is\nmorally acceptable then it is.<\/strong><\/p>\n\n\n\n Fact: <\/strong>What makes any doctor more of a moral expert than\nyour own conscience and learned values. Doctors have been elevated to new age\npriests but they only have the exact same claim to moral expertise as every\nother Canadian. A doctor, with all the attendant medical trappings and the halo\nof perceived goodness, provides false moral absolution and exoneration for a\nperson choosing suicide and using the doctor as the sanitized gun. It is a\ndance of mutual pretense that does not withstand the scrutiny of ethical\nanalysis. It is a suicide protocol masked by euphemism, false mercy, dissembling,\nwillful casuistry, or na\u00efve self-delusion about the righteousness of one\u2019s path\nand purpose. <\/p>\n\n\n\n Myth:<\/strong> MAID is consistent with each doctor\u2019s professional obligation\nto practice according to established standards of care.<\/strong><\/p>\n\n\n\n Fact:<\/strong> MAID for mental illness makes the doctor a\nconsumer controlled tool of death rather than an expert supporting healing and\nreducing suffering. Of grave concern is the effort of some legislators to allow\nMAID for mental illness without any statutory requirement that all standard or\nreasonable treatments have been tried before the patient is killed. The law as it\nstands says it is completely up to the person to decide if they are suffering\nunbearably and they can refuse standard treatments that might help them heal or\ncope. To allow people to choose death over and above proffered treatments for\ntheir illness is an unprecedented undermining of basic medical ethics and a\nphysician\u2019s duty to use their clinical skill and judgment to practice in accord\nwith established standards of care. A doctor cannot support offering death when\ntreatment is untried or incomplete.<\/p>\n\n\n\n Against such an unheard of legislative backdrop, what safeguards can\npossibly work?<\/p>\n\n\n\n Myth:<\/strong> A doctor helping a patient complete suicide is\nnot a moral issue in a secular and pluralistic society.<\/strong><\/p>\n\n\n\n Fact:<\/strong> Continuing religious,\nsocial, and ethical reflection would not support this claim. Beliefs and prohibitions about suicide and\ndoctors killing their patients have been held and argued for thousands of years\nbut in our secularized and pluralistic society the media, politicians, and\nacademia often relegate them to the sidelines in the forum of public debate.\nThe disparagement of religious\/faith-based perspectives is ironic given that\n70% of Canadians report holding faith- or spiritual-based values. Many publicly\nmask what they privately hold. <\/p>\n\n\n\n All\narguments for human dignity and mutual respect are primarily rooted in the\nreligious narratives that historically shaped Canadian law and values. MAID\nadvocates who dismiss objections to their position as being held by \u201creligious\npeople who can\u2019t tell me or society what to do\u201d have profoundly misunderstood\nand devalued the breadth of serious ethical analysis that underpins traditional\nreligious stances and attendant social structures. I wish I didn\u2019t feel a need\nto state the obvious, but bigotry is not ethically defensible, nor is it\nmorally acceptable in a pluralistic society.<\/p>\n\n\n\n Conscience\nrights are actually rooted in what informs our conscience: deep moral\nintuitions born of faith in something. Many good ethical arguments against physician\nassisted suicide are rooted not in faith-based or deontological claims but in\nrelational, utilitarian, virtue, and professional ethics. There are many lenses\nthrough which we can find common ground and we must have a thoughtful and open\ndiscussion of what assisted suicide means for us as ethical (religious or\nnon-religious) persons jointly forging caring societies.<\/p>\n\n\n\n Myth: A psychiatrist killing patients does not\nviolate medical professional ethics.<\/strong><\/p>\n\n\n\n Fact: <\/strong>The World Medical Association condemns MAID\nas an extreme violation of medical ethics. The American Psychiatric Association\nunequivocally condemns MAID for mental illness as an extreme ethical violation.\nThe Canadian Mental Health Association condemns MAID for mental illness. In\nfact, the long list of medical professional associations that condemn this\npractice the world over shines a bright light on Canada as an extreme moral\noutlier if it proceeds down this road. This social juncture is disturbingly\nreminiscent of the claim to \u201cprogressive thinking\u201d that many psychiatrists used\nto defend eugenics and forced sterilization within my lifetime. It absolutely\nmatters that the world community finds what we are considering morally\nabhorrent.<\/p>\n\n\n\n Myth:<\/strong> The majority of members of the Canadian Psychiatric\nAssociation support MAID for mental illness.<\/strong><\/p>\n\n\n\n Fact:<\/strong> The Canadian Psychiatric\nAssociation has most recently adopted a position of neutrality which supports\nnothing and everything, and undermines its own credibility by bowing to\npolitics over professional ethics and data. Only\n41% of the approximately 5000 Canadian psychiatrists are members of the\nCanadian Psychiatric Association. <\/p>\n\n\n\n In 2016, the CPA\nsurveyed its membership and 75% of the 500 respondents objected to MAID for\nmental illness. Without any further survey, or broad or expert consultation,\nthe CPA leadership released a position statement in 2020 that was developed by\nthe 7 member Professional Standards and Practice Committee. It said the CPA\nsupported MAID for mental illness because it was discriminatory to deny any\ncitizen with mental illness equal access to a service other Canadians had\navailable to them. It did not address the ethical or professional duty issues,\nnor did it consider the lack of evidence for irremediability of psychiatric\ndisorders, nor did it reflect the opinion of the majority of psychiatrists as\nexpressed in 2016, nor did it provide any balanced or considered statement\nrooted in the clinical expertise of its membership. The CPA openly acknowledged\nto members it had not even considered whether psychiatric conditions were\nirremediable, and if so, how that should be assessed. Its leadership chose to\nmake a political statement rather than a statement rooted in a serious\nconsideration of medical ethics, evidence, and the impact of suicide inducement\non vulnerable Canadians.<\/p>\n\n\n\n In 2020 the CPA leadership surveyed its members again\nwith what many members have described as a \u201cloaded survey\u201d. They reportedly had\nonly a 23% response rate. The full results of the 10 question survey have still\nnot been released to the membership or the public. Some CPA members report\nstarting the survey but then refusing to complete it because they felt it was\nso biased. To borrow Noam Chomsky\u2019s phrase, it seemed to be \u201cmanufacturing\nconsent\u201d. Any expressed support for the position that a patient should be\nconsidered eligible for MAID does nothing to clarify the issues of inadequate\ndata, irremediability, or professional ethics and duty. And asking whether members support\n\u201csafeguards\u201d (which of course members would if the practice became legally\nallowable) doesn\u2019t mean they want it legally allowable in the first place. <\/p>\n\n\n\n The 2020 position statement was quietly modified in\n2021 with a very different neutral position which can\nbe found on the CPA website: “There are compelling legal, clinical,\nethical, moral and philosophical questions that make this issue particularly\nchallenging. At this time, the CPA has\nnot taken a position on whether MAiD should be available in situations where\nmental illness is the sole underlying medical condition.” <\/strong>Despite this\nvery different position being posted on the CPA website, the CPA leadership has\nnot prominently announced this neutral stance to policy makers, media and the\npublic, nor did it testify to the significant change at parliamentary\nhearings. Instead the CPA has let\nmistaken public perception of its position stand uncorrected. Very recent media reports reflect this,\nincluding reporting in the national media citing support for MAID for mental\nillness on grounds that, \u201cThe Canadian Psychiatric Association has denounced\nthe exclusion (of mental illness from MAID) as discriminatory, stigmatizing and\nunconstitutional.\u201d I will note,\npsychiatrists are neither judges nor constitutional lawyers.<\/p>\n\n\n\n Attempts by several CPA members to have the issue\nof MAID and mental illness considered and discussed at the 2020 annual general\nmeeting were thwarted by an arcane procedural objection by the CPA leadership.\nDespite multiple members requesting a month and a half before the AGM that MAID\nbe added to the agenda, they were told they were too late (of note, at that\njuncture, the agenda had not been set, and notice for the AGM only went out two\nweeks later). <\/p>\n\n\n\n A working group was\nstruck to develop a new \u2018discussion paper\u2019 on MAID in 2020, many months after\nthe CPA had already released the aforementioned position statement. Some CPA\nmembers expressed concern that the new working group membership was weighted\nwith psychiatrists already well known to support MAID for mental illness\n(including those who had served as expert witnesses for groups advocating for\nexpansion of MAID for mental illness). Of note, membership did not seem to include\nor welcome experts who have publicly expressed caution regarding the expansion\nof MAID. <\/p>\n\n\n\n Instead of truly\nengaging members in response to criticisms, a past president of the CPA (who\npublicly challenged the actions of the CPA and criticized the lack of\nengagement in developing the CPA Position Statement, and the lack of evidence\nand consultation informing CPA\u2019s position) has been repeatedly accused by CPA\nleadership of \u2018misrepresenting\u2019 issues. <\/p>\n\n\n\n Nearly one full year\nsince the CPA released its Position Statement on MAID without member input, the\nCPA has still never asked members whether they agree with the 2020 Position\nStatement or with the CPA\u2019s positioning of the organization in the media on a\ncritical clinical and social issue. Many colleagues are now telling me that\nthey are struggling with whether to resign from the CPA or to enter into a battle\nwith a leadership so far removed from respecting the views of its own\nmembership.<\/p>\n\n\n\n Myth: Most psychiatrists support MAID for Mental\nIllness<\/strong>. <\/strong><\/p>\n\n\n\n Fact:<\/strong> Psychiatrists are split over MAID for mental\nillness. We have little data to establish the degree of the split, but enough\ndata to be certain there is a split. Anyone who claims there is an emerging\nconsensus based on the silence of the majority is simply speculating.\nPsychiatrists have critical experience and expertise but haven\u2019t been asked any\nclear questions that reflect complex clinical realities or legislative options. What can be said, as per public statements, is that\npsychiatrists on both sides of the issue do agree on\nthis: \u201cYou can\u2019t predict the course of illness for any individual patient\u201d.<\/p>\n\n\n\n Highlighting these differences shows the split, but the analysis of the\nvalues, life stories, clinical experience and acumen, and variance of\ninterpretation of the exact same data are what tell the story. It is\ncomplicated. What is not complicated is this. If MAID is allowed for mental\nillness, we know with 100% certainty that we will make fatal\nmistakes, and that we will take the lives of patients who would have gotten\nbetter…we just won’t know which. The hundreds of people who will die by MAID who would\nhave gotten better are not statistics. If it is your partner, or son, or\ndaughter, do you want a psychiatrist who supports MAID and is legally\nsanctioned to kill?<\/p>\n\n\n\n Myth: Safeguards will prevent abuses. <\/strong><\/p>\n\n\n\n Fact: <\/strong>The population of Canada is roughly 37 million\npeople. 50% of all Canadians have, or have had, a mental illness by the age of\n40 (19 million people). 44% of Canadians over age 20 have a chronic illness (16\nmillion people). 7 million Canadians have disabilities. Let\u2019s very\nconservatively estimate that 27 of the 37 million non-terminally ill people in\nCanada are about to potentially or eventually qualify for MAID when Bill C-7\npasses. And there are 92,000 MDs and 6000 NPs, all of whom can induce and complete\nassisted suicide. How, with those numbers, is it possible to administer and\nmonitor any practical safeguards? Does parliament really intend to swing the\ndoor that far open on a so-called \u201ctreatment of last resort\u201d? <\/p>\n\n\n\n Some doctors in the Netherlands have\nstated that if you don’t want physician assisted suicide, you should have\nyour wish written down and make sure your loved ones know, because otherwise it\nwill be assumed you want it. This presumption is a complete and unethical inversion\nof the long established informed consent protocol: patients are expected to\nopt-out of doctor assisted death rather than opt-in with clear consent. <\/p>\n\n\n\n Research\nfrom Belgium and the Netherlands shows over 30% of doctor caused death (I\nuse the word \u201ccaused\u201d not \u201cassisted\u201d because the patients didn\u2019t ask for\nassistance) went ahead without the consent of the patient (Smets et al,\nBMJ 2010). 47% of cases of physician\ncaused\/assisted death were not reported, despite the legal requirement to do so\n(this information comes from anonymous surveys of doctors). The reason for\nnon-reporting was most often because consent was not obtained. One such case\ninvolved a nun. The treating team felt her lack of request for a physician\nassisted death was because of her religious values being in the way and\nso, as an \u201cact of mercy\u201d, they killed her anyway. She didn\u2019t see it\ncoming. About a third of patients don\u2019t. It starts with a sedative in your\norange juice and you never wake up.<\/p>\n\n\n\n In Belgium and Netherlands, the requirement\nthat all treatments be tried before causing death was circumvented by doctors\nwho simply chose not to do so, without repercussion. Judges and monitoring\nbodies simply also ignored the legislated process safeguards. Patients\ndoctor-shopped to find doctors to approve their request for death; one\nparticularly infamous psychiatrist on a public crusade to relieve suffering has\nbecome a super suicide helper. To people who say that won\u2019t happen in Canada\nbecause we will set up a better and wiser monitoring system, I ask, how is the\nstate going to effectively monitor what goes on behind millions of examining\nroom doors shielded by confidentiality laws?<\/p>\n\n\n\n This\nis proactive social engineering rather than a response to citizen need, desire\nor request. Dr. Scott Kim (bioethicist\/psychiatrist) makes an important point\nthat the change in Canadian law will bring about a new reality where safeguards\nfall away in a self-fulfilling manner. It will become the moral norm and\nexpectation that an assisted death be chosen without \u201cmedical obstruction\u201d:<\/p>\n\n\n\n \u201cThe\nhope that we can protect psychiatric patients sufficiently by imposing a strict\nsystem of safeguards is based on a perspective prior to legalization of\npsychiatric PAD (physician assisted death). But we fail to note that the\nlegalization itself will likely change the social and practice context of how\nthe safeguards are applied. The very act of legalizing psychiatric PAD provides\nstrong support for it as a social good; this then becomes the context for\ncapacity determinations and the idea of a strict capacity threshold will begin\nto seem unnecessary, even obstructive. This is not a claim about a slippery\nslope of abuses and errors; the point is that the very norm of what an abuse or\nan error means will be recalibrated to the new reality, an apparently\nreassuring reality with no evidence of abuses and errors.\u201d (Kim S., 2016)<\/p>\n\n\n\n Furthermore, any requirement for X number of\nyears of treatment, or Y number of reasonable treatment trials, or Z number of\npsychiatric consultations, falters and fails against the backdrop of the\nunassailable legal principle of the absolute right of treatment refusal, and\nthe Bill C-14 entrenched principle of a subjective claim of unbearable\nsuffering being sufficient. Limiting eligibility over time is impossible in this\nlegal framework. This means that, in practice, proposed safeguards will not be sustainably\nenforceable. <\/p>\n\n\n\n If we knew there was a clear finish line when\ntreatment in a particular case could be proven to have failed, a safeguard\ncharade wouldn\u2019t matter as much. But there are no such finish lines for mental\nillnesses. Hence, we can only establish speedbumps but not change any\ndetermined person\u2019s ultimate demand for assisted suicide.<\/p>\n\n\n\n A law, that under the weight of its own legal\nprecedent, cannot set any sustainable limit on accessibility to what is\nsupposed to be a rare outcome of last resort is both na\u00efve and dangerous. It\nmeans the state has absolutely failed in its duty to protect its citizens.<\/p>\n\n\n\n Validating\nassisted suicide removes barriers, makes it the norm, and perversely makes\ncaution appear obstructionist.<\/strong><\/p>\n\n\n\n Myth: Maid for mental illness will have no\nunintended consequences.<\/strong><\/p>\n\n\n\n Fact: <\/strong>Today, my patient (in\nwhom psychotic symptoms resolved with medication over the past year) refused my\nsuggestion for psychotherapy as a next step. She said she wants MAID and that\n\u201cit will soon be legal\u201d, and she doesn\u2019t want psychotherapy because \u201cit might\nmake her change her mind about wanting MAID\u201d. My reason for wanting her to\nbegin psychotherapy is because she has been sick for so long that she now\nexpects to always be sick, and being a \u201cpatient in need\u201d has become her\nestablished means of eliciting support and care from others. My team can help\nher move to a healthier position in life where she can better meet her emotional\nneeds. Disturbingly, MAID is, in clinical lingo, \u201ca sick role reinforcement\u201d\npar excellence. We have to believe we can heal in order to take steps to heal.\nMAID proffered by a powerful and trusted physician says, \u201cstop hoping\u201d.<\/strong><\/p>\n\n\n\n In the short term:<\/p>\n\n\n\n In the long term: <\/p>\n\n\n\n Myth: Governments are not motivated to support\nMAID in order to save money.<\/strong><\/p>\n\n\n\n Fact: <\/strong>Killing certain\ncitizens saves money. It takes care of the \u201cproblem\u201d of the aging population.\nPalliative care is expensive. MAID pushes the marginalized beyond the final\nmargin once and for all. How else do you\nexplain the purpose of the recent parliamentary cost\nanalysis of implementing the new law? The government funded study said $150\nmillion would be saved in the first year. If MAID is an essential \u201cCharter\nright\u201d that must be offered no matter what, why was cost considered? Afterall,\nit is patently obvious that killing terminally ill people, and disabled people,\nand mentally ill people, and socially disadvantaged people, sooner than\notherwise, saves money. The social engineering agenda appears to be fostering an\nethos where people nobly kill themselves so that they are not a burden on\nothers. Additionally, doctors killing such persons is framed as a great act of\ncompassion rather than the commodification of death in a secular age. This is\nableism wearing a mask of virtuous hypocrisy.<\/p>\n\n\n\n Conclusion:<\/strong> We cannot know which mental illnesses are\nirremediable for any given patient. We simply do not have the data necessary to\nmake definitive clinical determinations, despite what some may falsely claim.<\/p>\n\n\n\n Most Canadians are\nunaware of this artificially pressured legislative push. And only about 10% of\npsychiatrists have weighed in. Some\nof my psychiatrist colleagues are shocked to hear death could be offered\nwithout the requirement that at least standard treatments have been tried. They\nhave absolutely no doubt that patients who would have gotten better will die if\nmental illness is not excluded in Bill C-7. And any proposed procedural\nsafeguards will falter and fail under the weight of individual physicians\nacting to normalize assisted suicide as a \u201cstandard practice\u201d rather than as an\noption of absolute last resort.<\/p>\n\n\n\n Canada offers MAID but\nnotuniversalpalliative care, disability supports, or mental health care. Do we\ncongratulate ourselves for our compassion in giving people an easier way to\ndie, while depriving them of the resources they need to live? How can Bill C-7 be justified while Canadians’ health rights are\nignored and unprotected? Is this what free choice\nlooks like in Canada?<\/p>\n\n\n\n John Maher MD FRCPC<\/strong><\/strong><\/p>\n\n\n\n Psychiatrist, Canadian\nMental Health Association<\/p>\n\n\n\n President, Ontario\nAssociation of ACT & FACT<\/p>\n\n\n\n Editor-in-Chief, Journal of\nEthics in Mental Health <\/p>\n","protected":false},"excerpt":{"rendered":" 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 \u201cdeath being reasonably foreseeable\u201d requirement and is opening the door for physician assisted […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_oasis_is_in_workflow":0,"_oasis_original":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-5591","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"\n