EXPERT ADVISORY GROUP (EAG) BRIEF TO PARLIAMENTARY COMMITTEE
MAY 30, 2022
The EAG recognizes MAiD is a complex topic spanning a range of opinions and belief systems. We hope the parliamentary committee honours its mandate to review the issues honestly and with integrity, to be guided by evidence and to avoid partisanship or personal bias from influencing its deliberations.
1. The 2020 EAG report found no standards exist for determining irremediability of mental illnesses, and evidence shows irremediability cannot be prospectively predicted in individual mental illnesses.[1] No evidence has emerged to change these conclusions, but rather to reinforce them.[2]
a. This means providing MAiD for sole mental illness defies the safeguard that MAiD be for a predictably irremediable medical condition. In making such determinations of “irremediability”, individual assessors would be making value-based, unscientific and arbitrary decisions falsely predicting irremediability and exposing non-dying patients to death by MAiD.
2. The AMPQ report (co-authored by the federal panel chair) acknowledges “It is possible that a person who has recourse to MAID could have regained the desire to live at some point in the future”, stating “Assessors will have to answer this ethical question [regarding certainty of eligibility] each and every time they evaluate a request.”[3] This dangerous position disregards science, evidence and medicine, and exposes individuals to arbitrary assessments potentially leading to death. This misuses the “medical expert” role, which should reflect physicians’ scientific and medical expertise, not their individual value-based ideologies.
a. The Gupta federal panel[4] echoes this dangerous idea. Despite being charged with recommending safeguards and protocols for MAiD for mental illness assessments, the panel failed to provide any specific guidance for determining “incurability” or “irreversibility”. The panel states “It is not possible to provide fixed rules for how many treatment attempts, how many kinds of treatments, and over what period of time” treatment should be required before providing death by MAID for mental illness, and recommends this decision be made on a “case-by-case basis”. This exposes patients to arbitrary unscientific assessments based on ideological values of assessors. Beyond reinforcing the continued impossibility of predicting irremediability of mental illness, the panel failed even in its mandate to provide standards or protocols.
b. Questionable assessments leading to death based on lack of standards are already occurring[5], [6], [7], [8], including patients wrongly deemed to have “irremediable” suffering which subsequently improved.[9]
3. The panel mentions risks to marginalized populations but ignores these concerns by concluding “no further legislative safeguards are required.”
a. Evidence shows psychiatric euthanasia places marginalized populations at risk of receiving premature death during periods of resolvable despair fueled by life suffering[10]. Canadians are already applying for and getting MAiD in these situations[11], which is drawing international condemnation.[12]
b. The panel glosses over these risks, ignoring the implications of multifold higher suicide rates of Canada’s Indigenous populations, fueled by historic intergenerational trauma, and higher suicide rates of other marginalized populations including LGBTQ2S+. In recommending no new safeguards and providing easier death to these groups, panel recommendations reflect attitudes of colonial privilege, further enhancing privileged autonomy for some while knowingly sacrificing other marginalized Canadians to premature death as a societal response to ableism, ageism, sexism and racism.
4. Dying With Dignity Canada released misleading information labeling it a “myth” that “Vulnerable populations can be eligible for MAID if they are suffering from inadequate social supports”, and saying “No one can receive MAID on the basis of inadequate housing, disability supports, or home care”.[13] This ignores common sense and established scientific evidence that one’s cumulative suffering is not just from illness but often fueled by life distress. A poor homeless two-spirited Indigenous young woman suffering from trauma and depression will not list “homelessness” as the reason for her MAiD request. They may nonetheless be provided societally assisted death to avoid life suffering when an assessor, based on his or her “ethical” opinion under guise of a medical treatment, unscientifically concludes their mental illness is “irremediable”.
5. The panel fails to address suicide risk in general.
a. The panel misrepresents the EAG report’s recommendations, suggesting our recommendation for a “non-ambivalence” safeguard somehow “does not apply” to MAiD for mental illness because the EAG did not support psychiatric euthanasia. To reiterate and avoid further misrepresentation of the EAG’s evidence-based view, quoting our 2020 report “A non‐ambivalence criterion should be required for MAiD in situations when death is not reasonably foreseeable”.
b. The panel’s failure to recommend a non-ambivalence safeguard ignores evidence of overlapping characteristics, including ambivalence, between those seeking psychiatric euthanasia and traditionally suicidal individuals benefitting from suicide prevention.[14]
c. The panel ignores data showing “assisted suicide is associated with a significant increase in total suicide (inclusive of assisted suicide) and no reduction in non-assisted suicide” in various jurisdictions, and that “it is women who have most been placed at risk of avoidable premature death”.[15]
d. The panel states “society is making an ethical choice to enable certain people to receive MAiD…regardless of whether MAiD and suicide are considered to be distinct or not”. The panel explicitly abdicates providing expert clinical input required for a ‘medical procedure’, and instead adopts a value judgement that privileged autonomy should take precedence over suicide prevention. This should not be misconstrued as medical expertise.
6. Former NIMH head Thomas Insel discusses the imprecision and unpredictability of psychiatric diagnosis and prognosis, and non-illness related factors driving wishes for death.[16] The Gupta panel’s recommendations do not responsibly reflect science; instead they reflect lack of evidence, lack of standards, and lack of accountability, allowing subjective assessments under the false guise of science.
In conclusion, evidence continues to show it would be irresponsible to provide MAiD for mental illness when predictions of irremediability can neither scientifically nor accurately be made, and it is impossible to differentiate MAiD requests from death wishes by suicidal individuals in these situations. Such expansion would reflect a push for increased privileged autonomy falsely under the guise of a medical procedure, and ignore the risks of unnecessary deaths to the most marginalized and vulnerable.
Respectfully submitted,
K. Sonu Gaind, MD, FRCPC, DFAPA, Honorary Member WPA
Chief of Psychiatry & Physician Chair MAiD Team, Humber River Hospital
Former President, Canadian Psychiatric Association
Professor, Temerty Faculty of Medicine, University of Toronto
Harvey Max Chochinov OC OM MD PhD FRCPC FRSC FCAHS
Distinguished Professor of Psychiatry, University of Manitoba
Senior Scientist, CancerCare Manitoba Research Institute
Former Chair, External Panel on Legislative Options to Carter versus Canada
Ramona Coelho, MD, CFPC
Family physician caring for marginalized populations
Paul Dagg, MD, FRCPC (he/him/his)
Clinical Professor and Associate Head, Department of Psychiatry
University of British Columbia
Sarah Garside MD PhD FRCPC
Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University
Vice-President, OAAF
Mark Henick, BA, MSc
CEO Strategic Mental Health Solutions
Mental Health and Suicide Prevention Advocate
former spokesperson Faces of Mental Illness Canada
Myeengun Henry
Former Chief, Chippewas of the Thames First Nation
Law Society of Ontario Indigenous advisor
Ontario Provincial Police Indigenous Advisor
Southern First Nations Health Access Traditional Healer
Scott Kim, MD
Adjunct Professor of Psychiatry, University of Michigan
Member, CCA Expert Panel on MAiD MD-SUMC
Marshall Korenblum, MD, FRCPC
Associate Professor, Department of Psychiatry, University of Toronto
Child Psychiatrist & Former Medical Director, Sick Kids Centre for Community Mental Heath
Consultant, Division of Youth Psychiatry, Sunnybrook Health Sciences Centre
Trudo Lemmens, LicJur, LLM bioethics, DCL
Professor and Scholl Chair in Health Law and Policy
Faculty of Law, University of Toronto
John Maher MD FRCPC
President, OAAF
Editor-in-Chief, Journal of Ethics in Mental Health
Rod McCormick, PhD
Kanienkehaka
Professor and BCIC Research Chair in Indigenous Health
Principal Investigator, Ombaashi Network
Director, All My Relations Centre, Faculty of Education and Social Work, Thompson Rivers University
Brian L. Mishara, PhD
Director, Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices
Professor, Psychology Department, Université du Québec à Montréal
The Honourable Graydon Nicholas, BSc, LLB, MSW, Order of Canada, Order of New Brunswick
Wolastoqiyik Nation
Former Lieutenant-Governor of New Brunswick
Harvey Schipper BASc, MD, FRCPC
Professor of Medicine, Adjunct Professor of Law
University of Toronto
Member, CCA Expert Panel on MAiD
Tim Stainton, PhD (he/him/his)
Professor, School of Social Work
Director, Canadian Institute for Inclusion and Citizenship
University of British Columbia
xʷməθkʷəy̓əm (Musqueam) Traditional Territory
Sephora Tang, MD, FRCPC
Psychiatrist, The Ottawa Hospital
Assistant Professor, University of Ottawa, Department of Psychiatry
Georgia Vrakas, PhD, psychologue & ps.éd. (elle|she|her)
Professeure agrégée, Département de psychoéducation
UQTR | Campus de Québec
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The Expert Advisory Group (EAG) on MAiD consists of diverse experts, psychiatrists and clinicians, including those involved in MAiD teams, psychologists, legal experts, medical ethicists and researchers, Indigenous leaders, those with lived experience and other cross sectionalities. The EAG issued its first report in February 2020 and reconvened following release of the federal Panel on MAID and Mental Illness report in May 2022.
REFERENCES
[1] Expert Advisory Group on MAiD: An Evidence-Based Critique of the Halifax Group IRPP Report. Feb 13, 2020. https://www.eagmaid.org/report
[2] van Veen S, et al. Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative. CMAJ April 04, 2022 194 (13) E485-E491; DOI: https://doi.org/10.1503/cmaj.210929
[3] https://ampq.org/wp-content/uploads/2020/12/mpqdocreflexionammenfinal.pdf
[4] https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.pdf
[5] Donna Duncan case: https://www.thespec.com/opinion/contributors/2022/03/16/maid-law-undermines-mental-health-care.html
[6] Alan Nichols case: Lemmens T. Medical Aid in Dying in Canada: A Case Raises Questions About Its Use in Patients with Disability and Mental Illness. International Network for the History of Neuropsychopharmacology (21 October 2021) online: https://inhn.org/index.php?id=4134 (with commentaries by Barry Blackwell, David Healy, Mark S. Komrad, Madelyn Hsiao-Rei Hicks & Marie Nicolini)
[7] https://nationalpost.com/news/canada/the-troubling-debate-over-a-good-death-for-anyone-who-chooses
[8] ‘Sophia’ case: https://www.ctvnews.ca/health/woman-with-chemical-sensitivities-chose-medically-assisted-death-after-failed-bid-to-get-better-housing-1.5860579
[9] ‘Denise’ case: https://www.ctvnews.ca/health/lifeline-for-woman-with-disabilities-approved-for-medically-assisted-death-after-mind-blowing-inspiring-support-1.5921893
[10] https://www.eagmaid.org/report
[11] CanadaLand “I Die When I Run Out of Money” podcast: https://www.canadaland.com/madeline-medical-assistance-in-dying-priced-out-of-life/
[12] Zhu YY: https://www.spectator.co.uk/article/why-is-canada-euthanising-the-poor-
[13] DWD Canada (accessed May 29, 2022): https://www.dyingwithdignity.ca/advocacy/myths-and-facts-medical-assistance-in-dying-maid-in-canada/
[14] Council of Canadian Academies. The State of Knowledge on Medical Assistance in Dying Where a Mental Disorder Is the Sole Underlying Medical Condition. 2018. https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-Where-a-Mental-Disorder-is-the-Sole-Underlying-Medical-Condition.pdf
[15] Jones DA. Euthanasia, Assisted Suicide, and Suicide Rates in Europe. JEMH. Open Volume 11, 2022. https://jemh.ca/issues/open/documents/JEMH%20article%20EAS%20and%20suicide%20rates%20in%20Europe%20-%20copy-edited%20final.pdf
[16] Insel T. Healing: Our Path from Mental Illness to Mental Health. Penguin Press. 2022.
