Why the “medical” in “Medical Assistance in Dying” (MAiD)?
The John and Edith Low Beer Memorial Lecture, put on annually by AMI-Quebec – Allies in Mental Health, in November 2024 focused on the controversial issue of Medical Assistance in Dying (MAiD) for Mental Illness. A panel discussion involving 2 psychiatrists and 2 individuals living with mental health challenges would highlight the complex perspectives associated with MAiD for mental illness.
Before the panel, I did a bit of research on the evolution of the law. The 2015 Supreme Court Carter decision had been largely prompted by the Sue Rodriguez decision 21 years earlier, a narrowly split decision in which 4 out of 9 Supreme Court justices concluded that the law criminalizing assistance to someone committing suicide violated their charter rights. Twenty-one years later, the rationale for prohibiting assistance on the grounds that it would protect vulnerable people from suiciding in times of weakness was found to be insufficient to justify a blanket prohibition on assisting suicide. Unfortunately, the Supreme Court justices, rather than proposing a solution of just repealing the criminal prohibition, suggested that doctors get involved.
In my view, that was a narrow and blinkered approach. In Switzerland, for example, there is no criminal prohibition against helping someone to kill themselves. Instead, there are a set of rules which govern, including that, for example, pills be self-administered. But even that is unnecessary. Canada and most other jurisdictions have laws against murder. If there is any doubt that helping someone to kill themselves was done in bad faith, or without adequate consent, etc. the laws against homicide would apply.
Instead of involving physicians (and pharmacists) in helping people to kill themselves (which for many represents a breach of their duty of care as well as an ethical and/or moral transgression) it would have been vastly less problematic to recommend to the federal legislators to repeal the law criminalizing assistance in suicide, and to recommend that the means necessary to “die with dignity” be made available to people with appropriate safeguards put in place. One does not need a doctor’s prescription or to have a pharmacist dispense rat poison, guns and ammunition, or even rope to hang oneself. But those ways of dying, along with driving one’s car into a concrete abutment or jumping off a high bridge, are messy and extremely distressing to the people left behind, never mind often painful, as well as often resulting in significant (and costly) disability rather than death.
There are preferable ways of dying with dignity. For someone who is relatively opioid-naive, a fentanyl patch of adequate strength can bring about a tranquil, painless death, comfortable not only for the person wishing to die but also for their loved ones. And I’m pretty sure I could teach even a child to apply a fentanyl patch properly and safely.
Are there ways to make the means of dying with dignity, such as fentanyl patches, available to people without a physician’s prescription and a pharmacist’s dispensation? Governments tend to believe that they can come up with safeguards, procedures, and processes to prevent firearms from falling into the wrong hands. Surely we can come with effective ways to control other means of dying!
Watching and listening to the panel discussion that AMI-Quebec organized on 2 November 2023 strengthened my feeling that proponents of MAiD, and especially MAiD for people with only mental illness, are driven by an ideology, and not by an empathic connection with people who are suffering. In Quebec, for example, some doctors supported changes to the law to permit MAiD because, they said, doctors were afraid that they might get into trouble if they engaged in what was the practice at the time, “terminal sedation”, ie use of sedating medication and opiates in doses sufficient to control pain but which might also impair respiration and lead to death. I contacted the Syndic of the Ordre des Médecins du Québec, my professional order, to ask if any physician in Quebec had ever been investigated or charged, either by the Order or by police, because they had “terminally sedated” someone. The answer was an unequivocal no.
In the late 1990s, as a geriatric psychiatrist on staff at the Jewish General Hospital in Montreal, I was the consultation-liaison psychiatrist to the Oncology Clinic, the Palliative Care teams (inpatient and outpatient), and also the Chronic Pain Clinic. As I was seeing cancer patients who were in pain, who were depressed, and who were sometimes suicidal, I explored ways in which I could be helpful. Experienced clinicians in this area made the point that most cancer patients with severe pain who wanted to die, changed their minds when pain was adequately controlled and their depression and hopelessness adequately addressed. In other words, quality palliative care. Sadly, many patients who could have benefited were unlikely to even have palliative care suggested to them by their oncologists, who often felt that doing so was an admission of failure on their part.
Perhaps even worse, most of my psychiatric colleagues were unable (and remain so) to think outside of the box that the pharmaceutical industry has put them into. Effective and rapid treatments for depression, such as partial sleep deprivation or methylphenidate, are beyond their ken. I have over the years asked many people who have received or are receiving treatment for depression whether either of these modalities have ever been proposed by their clinicians. Invariably they respond no.
As a consequence, I have a huge problem when people who are intelligent enough to know better insist that there are psychiatric illnesses for which there is no hope of improvement. They are just plain wrong! And it is also upsetting to be confronted with people who have taken the modern equivalent of the Hippocratic Oath who appear eager to end someone’s life! Clearly, we need better processes in place to screen out such people from even getting into medical school in the first place.
So, my plea to governments at both federal and provincial levels would be: improve access to quality palliative care; repeal laws against assisting suicide; and provide ways for the means for dying with dignity to be available to people with appropriate safeguards to prevent misuse, abuse, and other harms.