Policy Options, a Canadian forum, published the piece below by Jocelyn Downie, David Wright and Mona Gupta, all of whom I know, as a contribution to a wider debate on the Medical Assistance in Dying (MAiD) legislation currently under review in Canada, and especially the question of where does mental illness fit into this mix. The Downie and colleagues published piece is HERE.
The focus in this debate so far has been on the individual seeking MAiD which the Downie piece brings out. Mental Illness does bring individual irrationality into the frame. But is it just the person with a so-called mental illness. What about their doctors? While there are many great people in Healthcare, the experience of people with ‘mental disorders’ is often that those ‘caring’ for us can be far more murderous – in practice if not by intention – than anyone imagines. Those caring for us are not always angels – a series of posts on RxISK tagged Medical Kidnap bring this point out.
Policy Options invite submissions but never acknowledged this submission. I contacted them directly nearly a week later and they said they would pass on this one. Which left little option but to post here.
Jocelyn Downie, David Wright, Mona Gupta
Should people with mental illness as their sole underlying medical condition be allowed to have access to medical assistance in dying (MAiD)? That’s a question in front of Parliament right now. The House of Commons has passed a Bill that excludes MAiD for persons suffering from mental illness as their sole underlying medical condition. The Senate amended that Bill to put a sunset clause on the exclusion (it will cease to have any force and effect 18 months from the coming into force of the Bill). Soon the amended Bill will be back before the House, which will have to decide whether to accept the amendment.
Notably, in its report on Bill C-7, the Senate standing committee on legal and constitutional affairs wrote that some witnesses “underscored that an exclusion and strong safeguards are needed to protect Canadians with mental illness under a MAiD regime, especially given that suicidality may often be a symptom of certain mental illnesses.” Unfortunately, this way of thinking about the relationship between suicide and MAiD confuses more than it clarifies.
Suicidality is associated with certain psychiatric diagnoses, but by no means all or even most of them. Furthermore, not all persons who are suicidal have a mental illness. Rational suicide – the desire for individuals not suffering from a mental illness to end their own lives – has always existed. Indeed, the entire project of MAiD is premised on the idea that there are individuals who under certain circumstances have justifiable reasons to end their own lives. In addition, Parliament has already taken the position that the presence of a mental illness itself does not exclude the possibility of a rational desire to die, as there are people who have already legally accessed MAiD who suffer from both mental illness and physical conditions concurrently. (See the Feb. 2 testimony of Dr. Derryck Smith at the Senate standing committee, at the18:02:40 mark.)
From a clinical point of view, decisions to try to prevent someone from dying are not motivated by the mere presence or absence of a diagnosable mental illness. Rather, we intervene in order to try to modify their specific circumstances, such as a personal crisis, or the acute symptoms of their illness. Our actions also depend on whether the person is able to act in their own interests. We are likely to intervene to prevent the death of a person who is considering suicide when they lack decision-making capacity, for instance when they are severely intoxicated, even if they have no psychiatric history.
By contrast, we do not necessarily intervene to prevent the death of a person who wants to refuse life-sustaining treatment or to access MAiD due to a physical condition even if this person has a concurrent serious, and chronic, psychiatric condition. The answer to the question –does this person have a mental illness? – does not tell us whether we should prevent or assist the person ending their life.
When it comes to mental illness and MAiD, therefore, we must determine whether an individual seeking to bring an end to their life should be prevented from doing so, or not. Trying to decide whether the person is “suicidal” is simply shorthand for talking about the kinds of circumstances previously mentioned – personal crisis, acute episode of illness, incapacity, among others – where collectively, we have already determined that we should intervene to prevent a person from acting. The possibility of permitting some individuals with mental illness to make a request for MAiD does not impede suicide prevention efforts in these kinds of circumstances.
Thus, the statement “suicidal behaviour can often be a symptom of mental illness” is at once too broad and too narrow. It misuses the idea ofa symptom as a proxy for situations in which we want to act to prevent death. And by focusing on only those circumstances in which suicidality is a symptom of a mental illness, it simultaneously ignores the fact that there may also be situations in which we want to prevent death amongst those with no diagnosed mental illness at all.
By legalizing MAiD, Canadian Parliament has already decided that, in certain circumstances, it is acceptable to assist someone to die. Instead of excluding mental illness through a reflexive association between mental illness and suicide, we propose reframing the debate about MAiD and mental illness by asking: In which circumstances do we, as a society, wish to prevent death? In which circumstances, and under what safeguards, are we prepared to assist its arrival? By avoiding the shortcuts of medical terms, we can clarify what’s at stake and focus the debate on what criteria and safeguards will prevent those deaths that we should prevent.
Downie, Wright and Gupta’s points about MAiD centre on issues of capacity and consumerism.
Opting to end a life can indeed be quite rational. The role of medicine in their model is primarily to decide whether the person deciding to end their life has the capacity to do so. The focus is on the consumer of a medical service.
This neglects physicians. Medicine is the perfect place for a murderer to hide and medicine may have or have had more doctors who murder their patients than the Catholic Church has had paedophile priests. See Robert Kaplan’s Medical Murder – the image above is Harold Shipman, one of the cases he deals with. For these doctors, MAiD will be a godsend. There have always been physicians who find the removal of a healthy limb in someone with apotemnophilia technically satisfying. For the technician in some doctors, MAiD will be also satisfying.
Some physicians opt to do labioplasties and sculpt breasts rather than repair perforated duodenal ulcers but most distinguish between plastic and cosmetic surgery. The wider public view it as in the public interest to financially support the restoration of someone disfigured, perhaps while working on our behalf as a firefighter for instance, to something more like their normal self. We hope that in so doing s/he will be better able to contribute to the greater good. We sense, in contrast, that individuals seeking cosmesis should pay for themselves.
MAiD in the case of someone with terminal Motor Neurone Disease is something many doctors and a wider public would quietly support, but can we avoid paving way to cosmetic or romantic deaths?
For some decades, bioethicists have been concerned that doctors exercise ever less discretion in their dealings with us. Pharmaceutical corporations certainly believe that few doctors have a thought in their minds not put there by them or their competitors.
Company control has extended from the primary consumer, the doctor, to us who go to doctors having diagnosed ourselves with ADHD, ASD (autistic spectrum disorder) or other conditions, based on marketing materials put in our way by pharmaceutical companies. These diagnoses are fashionable and can suck people in, young people in particular, in the way cults do. While some doctors will try to persuade us that consumerism and poisons (medicines) or mutilations (surgery) are not natural bedfellows, and some of us can be persuaded, an increasing number of us complain if we are not given what we want. We have the rating scale score, where’s our drug?
We are now in a world of medical neo-liberalism. Health services have replaced Healthcare. We face Margaret Thatcher’s phrase of the 1980s – there is no alternative to the logic of the market. While clearly every case must be dealt with on its merits, are we saying anything goes? If anything goes, the strongest players in the game will give us as many disorders as they can and hook us into as many medical services as possible, even assisted dying.
In the case of patients with significant disabilities induced by treatment such as Enduring Sexual Dysfunction or Treatment Resistant Depression, who seek MAiD, will the panels see it as their brief to do anything about this? It’s difficult to imagine MAiD panels raising concerns about companies in the case of patients with lung or other cancers caused by tobacco or other carcinogens. Who benefits from viewing the administration of lethal agents in these circumstances as just a technical operation without entailing wider obligations?
MAiD as a health service contrasts with Healthcare which traditionally has been about relationships that enable people to endure and ‘heal’ – even when the condition is terminal. This is not something technicians or panels can deliver.
It has seemed appropriate to reserve the extreme form of caring that MAiD involves to illnesses rather than distress and extreme illnesses rather than just any disorder.
It has seemed appropriate to have a sanction of murder in place when a doctor supports a patient in this way requiring others to decide if this constituted care. It makes sense not to drag all doctors caring in this way through a murder trial, but by exactly how much do we want to loosen this sanction? Do we want doctors to simply carry out a technical procedure without engaging in the wider issues on behalf of their patient?
This is where the submission to Policy Options ends. The original submission had Robert Kaplan’s book in mind but did not mention it.
MAiD can be an act of caring – it can also be the ultimate symbol of the Medical Consumerism whose rise and growing force Shipwreck of the Singular charts and attempts to tackle
Having walked across Sydney Harbour Bridge yoked to Jocelyn Downie I have a permanent attachment to Jocelyn and I know both David and Mona from 20 years ago when I was having difficulties in Toronto – so this comment is not aimed at them in any way. It reflects my surprise at what seems to be a blind spot in the debate so far.
Finally one of the main driving force behind the debate in Canada – or perhaps that should be braking force is Trudo Lemmens who has been raising concerns for several years about these issues – see Here for his latest. I know Trudo from 20 years ago also – when Jocelyn, David, Mona and both he and I were all on the same side as I’m sure most people in these debates actually are. The trick is to avoid one more instance of good intentions leading to a nightmare.