MAID debate derailed by alternate facts

When introduced in 2016 for those whose deaths were foreseeable, Canadians knew medical assistance in dying (MAID) was for helping relieve end-of-life suffering. When the government expanded MAID in 2021 to people with a disability who were not dying, we were stepping into the unknown without evidence informing policy. Now, with the continued push for psychiatric euthanasia, we have moved beyond evidence-free policy to “alternate facts.” When MAID was expanded in 2021 beyond foreseeable death situations, evidence suggested that some non-dying people with a disability would seek MAID not to avoid end-of-life illness suffering, but to escape unresolved social anguish. We just did not know how many marginalized disabled would seek MAID for those reasons. We are now seeing regular headlines of disenfranchised Canadians with disabilities—disabilities providing a “foot in the door” to the MAID regime—being provided state-assisted suicide for poverty, loneliness, and housing insecurity. Ignoring that each of these reflects a human life society has actively ended, expansion advocates minimize concerns as this “being a small number of cases.” Concurrently, further expansion of MAID to sole mental illness conditions is propelled by fact-free arguments. Expansion proponents like Senator Stan Kutcher, the psychiatrist who introduced the sunset clause to allow psychiatric euthanasia, play off the real pain stigma has caused for centuries, and claim it would be discriminatory not to provide MAID for mental illness. While seductive in its simplicity, this characterization is misleading. Most would think the real discrimination is exposing marginalized people with mental illness to premature death, based on faulty assessments by MAID providers reinforcing their despair that they will never get better, even though many would. The emotional appeal that MAID expansion is just about individual autonomy is equally specious. Expanded MAID is about privileged autonomy. True autonomy requires true choice, and marginalized individuals face very different options than physicians, or Senators. Additionally, MAID is not about an individual’s right to do something autonomously, it is about an expected entitlement to have society provide one a facilitated death. This obviously impacts others, not just the individual claiming autonomy. K. Sonu Gaind is a professor at the University of Toronto, chief of psychiatry and physician chair of the MAID Team at Humber River Hospital, and a former president of the Canadian Psychiatric Association. Photograph courtesy of K. Sonu Gaind Canadians have been told that MAID is meant for “irremediable” medical conditions, or ones that will not get better. While some assessors wrongly believe they can make these predictions, evidence shows it is impossible to predict any individual’s mental illness will not get better. These attempted predictions are no better than flipping a coin, or worse. Some expansionists acknowledge this reality, but claim it does not matter. Dr. Mona Gupta, chair of the federal panel tasked with developing “how-to” guidelines for providing MAID for Canadians living with mental illness, authored a 2020 report advocating for psychiatric euthanasia while acknowledging that, “It is possible that a person who has recourse to MAID—regardless of his condition—could have regained the desire to live at some point in the future.” Expansionists dismiss this lack of predictability by falsely conflating it with other uncertainties or “miracle cures.” Yet there is simply no comparison between the more predictable course of cancers or neurodegenerative diseases that have shaped our MAID laws, and the unpredictability of mental illnesses (even untreated) of which we do not understand the biology. Other assessors claim they would provide patients an “informed choice” by telling them of this uncertainty that they might improve, yet on the MAID forms (as legally required, lest they face criminal charges) they would still indicate that “the illness is irremediable.” If those suffering from mental illness would not get MAID for predictably irremediable medical conditions, what would they be getting MAID for? This is where the debate shifts from evidence-free to alternate facts. In defending plans to implement MAID for mental illness in 2024 after a one-year delay, Mental Health Minister Carolyn Bennett claimed that psychiatric MAID is not suicide, professing that practitioners are “very good” at separating “suicidal ideation from MAID for a mental health condition.” In fact, evidence shows the opposite is true. We cannot distinguish suicidal wishes, ones that respond to suicide prevention strategies, from those seeking psychiatric MAID. Even Justice Minister David Lametti has acknowledged that expanded MAID “is a species of suicide.” When the minister of mental health and addictions wrongly reassures that assessors can weed out suicidality in psychiatric MAID requests, despite known evidence clearly indicating otherwise, the discourse becomes dangerously fact-free. Lametti has repeatedly claimed there is a court mandate to allow MAID for mental illness. More concerning than avoiding responsibility using the “we had to do it” rationale, the legitimacy of this claim coming from the minister of justice is questionable. Neither Carter nor Truchon, the cases shaping our MAID policies, even involved patients with mental illness. At the beginning of February, 25 prominent legal scholars wrote to cabinet, contesting the government’s assertions that psychiatric euthanasia has been mandated by the courts, yet Lametti continues repeating this claim to justify planned expansion. Our MAID policies should not be driven by alternate facts. For the recently announced one-year pause to have meaning, the time must be used to develop policy following unbiased review of evidence, rather than presupposing further expansion must occur. Simply deferring the same pre-determined outcome downfield would reflect the madness of repeating our mistakes rather than learning from them. K. Sonu Gaind is a professor at the University of Toronto, chief of psychiatry and physician chair of the MAID Team at Humber River Hospital, and a former president of the Canadian Psychiatric Association. Find him on Twitter: @Psych_MD. The Hill Times