Published on October 18th, 2017 | from CAMH
Medical Assistance in Dying and Mental Illness
By Dr. Tarek Rajji, Chief of Geriatric Psychiatry, CAMH
Physician-assisted suicide has been legal in several countries and states around the world for 20 years. In Canada, Medical Assistance in Dying (MAiD) has been legal since June 2016. MAiD in Canada is available to people with grievous and irremediable medical conditions, who are in a state of irreversible decline, and whose death is in the foreseeable future. A question we are asking ourselves now as Canadians: how should MAiD relate to mental illness?
Complexity is at the core of psychiatric issues. As a psychiatrist, I see MAiD for mental illness as another complex subject where we – physicians, clinicians, academicians, clients, patients, family members, caregivers, and administrators – need to listen to each other and develop a common language to navigate through this complexity.
As a psychiatrist, I see the grievousness of mental illness first hand. Many clients suffer intolerably from incurable medical conditions of the brain. They come to my clinic, some week after week, and we work together towards finding the right treatment to alleviate this suffering. Some get relief and others don’t. Others come to my clinic week after week and we work together towards finding a way to live with mental illness, to set a meaningful and “normal goal” to achieve, like having a friend or finding a job, and not just hearing voices less, or sleeping better at night. Some achieve these goals and find more meaning in their lives. Others don’t and some decide to stop coming. As a psychiatrist, for all of those clients and patients, my promise is the same: my clinic will always be open and I will not give up hope that working together will produce results. Why do I make this promise?
I make this promise for two reasons: First, because I am driven by the hope for recovery. Second, because our field of psychiatry has not reached a state of knowledge that is precise enough to tell me whether the patient in my office who is suffering from a grievous psychiatric condition is also suffering from an illness that is irremediable and if the patient is in a state of irreversible decline with death in the foreseeable future. This inability to predict at the individual level, combined with a framework of hope and recovery, allows me to make this promise to my patients and their family members. So what about MAiD? With this promise being at the core of my practice, MAiD on the basis of mental illness alone negates this promise and closes my clinic.
Nearing death is a key criterion for MAiD. While many of our patients at CAMH die because of their mental illness, we are far from predicting whether the unique patient in our office is nearing death or not. For an older person with mental illness, this criterion becomes even more complex and I urge us not to fall into an ageism trap of using a statistical life expectancy to predict at the individual level whether this older person sitting in our office is nearing death or not.
CAMH’s MAiD Working Group that I was a part of spent almost two years discussing and debating MAiD for mental illness with our colleagues, people with lived experience of mental illness and other experts. CAMH came to the decision that the federal government should not make an amendment to MAiD legislation for people with mental illness as their sole underlying medical condition at this time due to a lack of evidence that mental illness is an irremediable medical condition.
This was not an easy decision for CAMH to come to. But I agree with the decision as it is consistent with my principles as set out above. I would encourage you to read CAMH’s full Policy Advice Paper on Medical Assistance in Dying and Mental Illness. As psychiatrists, we cannot stay out of it. We cannot ignore, avoid, or just rubber stamp our patients’ requests for MAiD. This is not only because of the “medical” in MAiD but also because of our duty to advocate for the best evidence-informed care for our clients.
MAiD is another layer of complexity around mental illness. I invite us – physicians, clinicians, academicians, clients, patients, family members, caregivers, and administrators – to hear each other’s suffering and ethical dilemmas and to use reason and science as our common language while we work together to advance our knowledge of patients’ trajectories, to develop new treatments, and discover new ways of hope and recovery.