L'association des medecins psychiatres de Quebec publishes paper “Access to medical assistance in dying for people with mental disorders”. Complex issue cannot be discussed fully. But timing no coincidence, so let's look at some deeply troubling issues (1) bit.ly/37Aqlxs
(2) Authors clearly know they feed into a process of Bill C-7 & endorse inclusion of MH; but Bill’s provisions DO NOT provide a reliable, safe basis for what even they recommend as minimal standards under which MAID for MD could be practiced
(3) 'in their view', as this is presuming that the reports’ recommendations are ethically sound/unproblematic, legally coherent, and evidence-based. Not so, imho. Let’s look at some components.
(4) Subtitle of report revealing: “Provide appropriate care; Recognize suffering & autonomy; Respect the right to dignity”. Conspicuously ABSENT:...core Charter/Human Right: "right to life" Reflects imho remarkable focus on death as therapy, prioritized over safeguards to prevent
(5) Report states “whether to permit MAID MD-SUMC is not an empirical question, it is an ethical one. Empirical research can help to support ethical arguments but cannot replace the necessary moral deliberation”. So what about ethics?
(6) While report suggests ‘it’s an issue of ‘ethics’, suddenly, when ethical & empirical arguments fail/are absent/too hard, it becomes an issue of "rights". Some examples...
(7)"Association [des psychiatres] does not intend to promote MAID MD-SUMC, but recognizes suffering of patients & RIGHT to MAKE THEIR OWN CHOICE like any other person.” So is open-ended ‘right to choose’ same as DUTY FOR STATE TO ORGANIZE MAID AS THERAPY for Mental disorder?
(8) Note "like any other person" BUT: under current Bill, if mental health included, everyone with disability, chronic illness (incl. mental disorder) gets benefit of state organized & medical profession provided ending of life. NOT SO FOR ALL OTHERS (but perhaps that will come?)
(9) Same 'rights' language in report when MAID for ‘persons with intellectual disabilities’ is discussed. --Authors want to make sure no category is left behind (only category they recommend requiring 'further study': "prisoners w wish to die to avoid serving a sentence"!!!)--
(10) Why not recognize, as per the report's lip service to 'eugenics' and discussion of social problems & vulnerability of persons w intellectual disability “to all types of abuse and …. external pressure”, that MAID for Intellectual disability is DEEPLY PROBLEMATIC?
(11) But if ethics is unclear, authors jump to rights: “it is important to balance these considerations with ensuring FULL ACCESS TO THEIR RIGHTS AS CITIZENS, including their entitlement of self-determination... ” So: let's make sure PwIntellectual disabilities can get MAID
(10) Do I need to remind those still reading that CSC did NOT recognize unconstrained open fundamental right to die w dignity? Do you think our SC justices really thought there should be a RIGHT to MAID for Intellectual Disability? If so, well, not my vision of human rights
(11) So it's about ‘rights’; not ethics & science? Still, authors (mostly psychiatrists) realize they need to counter key evidence-based arguments of diagnostic uncertainty and challenges of prognosis in context of "mental disorders"
(12) so what about those challenges? "uncertainty can exist even in cases of physical illness as well as physical and psychiatric comorbidity. [MAID for sole reason of Mental Disorder] cases are no exception.” So there you have the solution...
(13) Obviously, medical uncertainty exists in many areas of medical practice. But how can 6 psychiatrists sign a document that so superficially brushes over one of the core challenges in psychiatry? Statement undermines even scientific integrity of report & further reveals intent
(14) diagnostic uncertainty & prognostic uncertainty ARE core challenges of MH practice in a way that is incomparable to other areas of medicine where MAID is practiced. Why ignore it?
(15.1) Politically problematic nature report also this: report feeds into process of Bill C-7, but core components of the bill incompatible with minimal safeguards that even those psychiatrist who deem MAID for MH acceptable seem to require, as authors acknowledge
(15.2) Bill C-7 explicitly fails to require all treatment options need to be tried out first; assessment 90 d suffices--reflects (imho problematic) trust in ease of determining unbearable suffering, irremediability, irreversible decline
(15.3) psychiatrists do not see this as an obvious issue in MH MAID, as per report: "existence of the criterion of intolerable suffering poses a massive challenge" (& note: even according to poll in report, still close to 50% of Que psychiatrists remain fundamentally opposed!).
(15.4) "minimum amount of time living with the disease must be more than five years before a request for MAID for persons with MD-SUMC can be made. Moreover, 42% of those surveyed felt it should be no less than 10 years."
(15.5) "incurability of a mental disorder could therefore only be determined at the end of a long process, after attempting several treatments and assessing their effects." Note: no scientific source for 5-10 years, or 'long process'. Why: there is no reliable prediction!
(16) What about suicide prevention: “request for MAID for persons with MD-SUMC could be a form of suicide; ...allowing MAID for persons with MD-SUMC could thwart social prevention efforts.” But: for authors, this is not a real problem because ‘some other countries do it’!
(16.2) “In three countries where MAID for persons with MD- SUMC is allowed [B, Nl, SW] suicide prevention strategies as well as forensic procedures similar to those in Quebec are designed to protect people with a mental disorder and prevent them from harming themselves [....]"
(16.3) "This SUGGESTS that such practices should not be considered to be contradictory and that they could coexist." 2 comments: 1. only B-Nl has physician-provided MAID like Canada. 2. "suggests"= key term since: ABSENCE OF EVIDENCE! see p18/19 report eagmaid.org/report
(16.4) Indeed: NO EVIDENCE that suicide prevention is NOT impacted by MAID MH. Complex to determine what causes suicide rates, but reasons to think suicide prevention IS IMPACTED by MH MAID. See EAGMAID report + e.g. statements NL suicide prev. centre trudolemmens.wordpress.com/2018/06/19/she…
(17) All this to say: this Quebec MH MAID discussion paper reflects another extraordinary attempt to justify, on the basis of some distorted idea that "people have an open-ended constitutional right to MAID", a broadening of MAID in an extremely complex area of health care...
(18) without evidence that it is a 'safe' practice (even according to the norms set out by those defending it for this area of health care), without proper ethical justification, w superficial rights-claims + an astounding trivialization of social determinants MH & historic abuse
(19) One wonders what purpose was of @cca_reports on MHMAiD, intended to provide balanced information for fulsome parliamentary debate, if professionals, including some CCA Ctee members, now leap into a rushed legislative process, pushing for broad access w-out full review
see v long thread re recent Quebec report on MH MAID, of interest to discussions on Bill C7 and arguments about inclusion of MH @SenJaffer @denisebatters @KPateontheHill @Psych_MD @markhenick @georgiavphd @ProfTimSUBC @DrSandySimpson
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