The Final Report of the Expert Panel on MAiD & Mental Illness
This is a review of the Final Report of the “Expert” Panel on the provision of Voluntary Euthanasia to the Mentally Ill in Canada, released 13 May 2022. (VE primarily, but includes the option of Assisted Suicide.) The formal term is ‘Medical Assistance in Dying for Mental Disorder as a Sole Underlying Medical Condition’ [MAiD MD-SUMC.]
It is tragic that some health-care professionals are now considered to be expert in euthanizing patients.
MaiD MD-SUMC was legislated through Bill C-7 in 2021, though implementation was deferred till March 2023. This means that from early next year, Canadians suffering from mental illnesses alone will be able to request, and to possibly receive, Voluntary Euthanasia, or Assisted Suicide.
The link to the PDF of the report:
final-report-expert-panel-maid-mental-illness.pdf (canada.ca)
Political limitations
I found one statement in the 136-page report which noted a significant limitation to the mandate for the Expert Panel. (Some might say buried?!)
“The Panel’s Terms of Reference (Appendix A), indicated that its role was not to debate whether or not persons with a mental illness as their sole underlying medical condition should be eligible for MAiD.”
Clearly the Expert Panel was expected to ‘rubber stamp’ the process for MaiD MD-SUMC and that the process would provide some sense of a “scientific approach.” (It is curious that 2 panel members resigned before the final report was released.) On this basis, I restricted the review to the panel’s recommendations.
Definitions:
Medical Assistance in Dying [MAiD]: is primarily Voluntary Euthanasia, but includes Assisted Suicide [AS.] This was legislated first in 2016 and amended in 2021 with loosened criteria.
Medical Assistance in Dying for Mental Disorder as a Sole Underlying Medical Condition [MaiD MD- SUMC]: Voluntary Euthanasia and AS for people suffering from a mental illness alone. Legalized in 2021 through Bill C-7 but deferred enacting till March 2023.
Suicidality: The American Psychological Association defines suicidality as: “the risk of suicide, usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan.”
Suicide Behavior Disorder (SBD) DSM-V: “As proposed currently a diagnosis of SBD would require an individual to meet all five of five of the following diagnostic criteria:
A. Within the last 24 months, the individual has made a suicide attempt.
B. The act does not meet criteria for non-suicidal self-injury (NSSI).
C. The diagnosis is not applied to suicidal ideation or to preparatory acts.
D. The act was not initiated during a state of delirium or confusion.
E. The act was not undertaken solely for a political or religious objective.”
[https://www.frontiersin.org/articles/10.3389/fpsyt.2020.499980/full]
The Recommendations
The Expert Panel made 19 recommendations. Many are so basic that they can hardly be perceived to be “expert” advice. Certain aspects of the recommendations are discussed below. (Full text can be found in Appendix I.)
1. ‘Development of MAiD Practice Standards’
“We need to develop Standards of Practice.”: Surely, this was the stated mandate?!
2. ‘Establishing Incurability’
“It is not possible to provide fixed rules for how many treatment attempts, how many kinds of treatments, and over what period of time as this will vary according to the nature and severity of medical conditions the person has and their overall health status. This must be assessed on a case-by-case basis.”
So, there will be ‘no fixed rules’ on establishing incurability and applicants will be assessed on a ‘case-by-case basis.’ This means the decision to euthanize a suicidal person will be based on the subjective decision of the assessing doctors / Nurse Practitioners [NP’s.] No objective measure is a recipe for disaster.
3. ‘Establishing Irreversibility’
“It is not possible to provide fixed rules for how many attempts at interventions, how many types of interventions, and over how much time, as this will vary according to a requester’s baseline function as well as life goals. Therefore, this must be assessed on a case-by-case basis.”
Again, there will be ‘no fixed rules’ for establishing irreversibility and the applicants will be assessed on a ‘case-by-case basis.’ This means the decision to euthanize a suicidal person will again be based on the subjective decision of the assessing doctors/NP’s. No objective measure is another ingredient in the recipe for disaster.
4: ‘Enduring & Intolerable Suffering’
“MAiD assessors should come to an understanding with the requester that the illness, disease or disability or functional decline causes the requester enduring and intolerable physical or psychological suffering.”
Again, the decision to euthanize a suicidal person will be on the subjective opinion of the assessing doctors/NP’s. A third major criterion without any objective measure.
5. ‘Comprehensive Capacity Assessments’
“MAiD assessors should undertake thorough and, where appropriate, serial assessments of a requester’s decision-making capacity in accordance with clinical standards and legal criteria.”
Initially, this seems very reasonable. It would be better to have people who are not MAiD providers to do the assessments for competency, coercion and duress.
6. ‘Means Available to Relieve Suffering’
“ ‘community services’ …should be interpreted as including housing and income supports as means available to relieve suffering and should be offered to MAiD requesters, where appropriate.”
It is to Canada’s shame that people have already been euthanized because of poverty.
Poverty, lack of appropriate housing and lack of adequate home-care support is a form of societal coercion. That alone should be a contraindication to the provision of MAiD & MaiD MD-SUMC.
Kevin Yuill wrote the poignant SPIKED article about people who took MAiD because they could not find affordable, chemical/allergen-free housing. Remember the Case of Roger Foley in Ontario who wanted to live with self-structured Home Care, but was offered MAiD instead.
7. ‘Consideration to the relief of suffering’
“Serious consideration should be interpreted to mean genuine openness to the means available to relieve suffering and how they could make a difference in the person’s life.”
So, if referring to the applicants, they are way past ‘openness’ to alternative treatments by the simple fact they are asking to die.
Then, if referring to the providers, they are ‘relieving suffering’ through MaiD MD-SUMC, but somehow now they are going to significantly delay to use other treatments? In general, no.
8. ‘Consistency, Durability, and Well-Considered Nature of a MaiD Request’
“Assessors should ensure that the requester’s wish for death is consistent with the person’s values and beliefs, unambiguous and rationally considered during a period of stability, not during a period of crisis.”
The applicant is asking to DIE. When would that happen without some crisis in their life? (They may be referring to a ‘period of stability’ in the mental illness.)
9. ‘Involuntariness’
“Persons in situations of involuntariness for periods shorter than six months should be assessed following this period to minimize the potential contribution of the involuntariness on the request for MaiD. For those who are repeatedly or continuously in situations of involuntariness, (e.g., six months or longer, or repeated periods of less than six months), the institutions responsible for the person should ensure that assessments for MaiD are performed by assessors who do not work within or are associated with the institution.”
“Involuntariness” is a euphemism for those who are committed to a mental hospital under their respective Mental Health Act (enforced incarceration & treatment, for their safety or the safety of others.) The idea that a person who is specifically under the Care of the State, can be assessed for euthanasia, beggar’s belief.
10: ‘Independent Assessor with Expertise’
“In cases involving MaiD MD-SUMC, the assessor with expertise in the condition should be a psychiatrist independent from the treating team/provider. Assessors with expertise in the person’s condition(s) should review the diagnosis, and ensure the requester is aware of all reasonable options for treatment and has given them serious consideration.”
The first part is an excellent suggestion. The second is very weak — the applicant just has to be “aware” of all reasonable options and has given them “serious consideration.” The applicant does not have to try ANY potential treatment/s.
11. ‘Involvement of Other Healthcare Professionals’
“Assessors should involve medical subspecialists and other healthcare professionals for consultations and additional expertise where necessary.”
This recommendation started well but fails on the “where necessary…” If a consultation is recommended, it should be a pre-requirement before MaiD MD-SUMC.
12 (a & b): ‘Discussion with Treating Team and Collateral Information’
(a) “If the requester’s primary healthcare provider is not one of the assessors, assessors should obtain input from that person. When the requester’s clinical care is shared by members of a multidisciplinary healthcare team, assessors should solicit their input.”
Excellent suggestion (which is not in the current legislation.) See the previous note on consultations.
(b) “With a requester’s consent, assessors and providers shall obtain collateral information relevant to eligibility and capacity assessment. This should include reviewing medical records, prior MaiD assessments, and discussions with family members or significant others. Care must be taken to determine that obtaining collateral information will not be harmful to the requester.”
Generally a great suggestion especially the collateral information from family members and significant others (Again, not in current legislation) but it seems odd that we are prepared to kill the person but consider it harmful to collect collateral information.
13: ‘Challenging Interpersonal Dynamics’
“Assessors and providers should be self-reflective and examine their reactions to those they assess. If their reactions compromise their ability to carry out the assessment in accordance with professional norms, they should seek supervision from mentors and colleagues, and/or discontinue involvement in the assessment process. The practitioner should adhere to any local policies concerning withdrawal from a MaiD assessment and onward referral.”
Generically this a reasonable recommendation.
The occasional MAiD provider is likely to be very self-reflective.
Regular MAiD providers are likely to be a unique sort of Health-Care provider and should have detailed psychological and/or psychiatric assessments. Certain traits should be a bar to being a provider.
14 to 19: ‘Implementation’ (Examples of generic recommendations)
14. ‘The need for consultation’ (with First Nations, Inuit, Métis Peoples etc.);
15: ‘the Training of Assessors/Providers’;
16: ‘having possible oversight by the federal government;’
17: ‘the provision of “Case-Based Quality Assurance and Education”;’
18: ‘the need for modification of data collection under the current MaiD Monitoring System; ‘
19: ‘the provision of Federally Funded Research.’
The Final Solution
Obviously some of the first to request MaiD MD-SUMC will be the older, chronically depressed or bipolar patients: some chronic schizophrenics may apply also.
There are no safeguards from MAiD being promoted to this very vulnerable population, many of whom are susceptible to suggestions from their caregivers and family etc.
Some have already voiced the potential of MAiD for young women with intractable Anorexia Nervosa.
“Tell me to stay…”
Just imagine the potential numbers who might qualify with Autism Spectrum Disorder, especially when MAiD is approved for “Mature” Minors (possibly down to 12 years of age.) Another potentially large and exceptionally vulnerable group are those suffering from severe Gender Dysphoria who have transitioned or de-transitioned. The moral ramifications of this are enormous.
The term for those who deliberately provoke a fatal response from the police is “Suicide by Cop.” The idea of a doctor or Nurse Practitioner colluding with a mentally ill person into causing their death has to be “Suicide by Doc.”
Kevin Hay
(You can follow Kevin on Twitter @kevinhay77)
APPENDIX I:
FULL TEXT of the Recommendations for MAiD Practice Standards:
Recommendation 1: Development of MAiD Practice Standards
The federal, provincial and territorial governments should facilitate the collaboration of physician and nurse regulatory bodies in the development of Standards of Practice for physicians and nurse practitioners for the assessment of MAiD requests in situations that raise questions about incurability, irreversibility, capacity, suicidality, and the impact of structural vulnerabilities. These standards should elaborate upon the subject matter of recommendations 2-13.
Interpreting Grievous and Irremediable Medical Condition
Recommendation 2: Establishing Incurability
MAiD assessors should establish incurability with reference to treatment attempts made up to that point, outcomes of those treatments, and severity and duration of illness, disease or disability.
It is not possible to provide fixed rules for how many treatment attempts, how many kinds of treatments, and over what period of time as this will vary according to the nature and severity of medical conditions the person has and their overall health status. This must be assessed on a case-by-case basis.
The Panel is of the view that the requester and assessors must come to a shared understanding that the person has a serious and incurable illness, disease or disability. As with many chronic conditions, the incurability of a mental disorder cannot be established in the absence of multiple attempts at interventions with therapeutic aims.
Recommendation 3: Establishing Irreversibility
MAiD assessors should establish irreversibility with reference to interventions tried that are designed to improve function, including: recognized rehabilitative and supportive measures that have been tried up to that point, outcomes of those interventions, and the duration of decline.
It is not possible to provide fixed rules for how many attempts at interventions, how many types of interventions, and over how much time, as this will vary according to a requester’s baseline function as well as life goals. Therefore, this must be assessed on a case-by-case basis.
The Panel is of the view that the requester and assessors must come to a shared understanding that the person is in an advanced state of irreversible decline in capability.
Recommendation 4: Understanding Enduring and Intolerable Suffering
MAiD assessors should come to an understanding with the requester that the illness, disease or disability or functional decline causes the requester enduring and intolerable physical or psychological suffering.
Vulnerabilities
Recommendation 5: Comprehensive Capacity Assessments
MAiD assessors should undertake thorough and, where appropriate, serial assessments of a requester’s decision-making capacity in accordance with clinical standards and legal criteria. These assessments should be consistent with approaches laid out in standardized capacity evaluation tools.
Recommendation 6: Means Available to Relieve Suffering
To ensure all requesters have access to the fullest possible range of social supports which could potentially contribute to reducing suffering, the Panel recommends that ‘community services’ in Track 2 Safeguard 241.2(3.1)(g) should be interpreted as including housing and income supports as means available to relieve suffering and should be offered to MAiD requesters, where appropriate.
Recommendation 7: Interpretation of Track 2 Safeguard 241.2(3.1)(h) the person has given serious consideration to those means
Serious consideration should be interpreted to mean genuine openness to the means available to relieve suffering and how they could make a difference in the person’s life.
Recommendation 8: Consistency, Durability, and Well-Considered Nature of a MAiD Request
Assessors should ensure that the requester’s wish for death is consistent with the person’s values and beliefs, unambiguous and rationally considered during a period of stability, not during a period of crisis.
Recommendation 9: Situations of Involuntariness
Persons in situations of involuntariness for periods shorter than six months should be assessed following this period to minimize the potential contribution of the involuntariness on the request for MAiD. For those who are repeatedly or continuously in situations of involuntariness, (e.g., six months or longer, or repeated periods of less than six months), the institutions responsible for the person should ensure that assessments for MAiD are performed by assessors who do not work within or are associated with the institution.
Assessment Process
Recommendation 10: Independent Assessor With Expertise
The requester should be assessed by at least one assessor with expertise in the condition(s). In cases involving MAiD MD-SUMC, the assessor with expertise in the condition should be a psychiatrist independent from the treating team/provider. Assessors with expertise in the person’s condition(s) should review the diagnosis, and ensure the requester is aware of all reasonable options for treatment and has given them serious consideration.
Recommendation 11: Involvement of Other Healthcare Professionals
Assessors should involve medical subspecialists and other healthcare professionals for consultations and additional expertise where necessary.
Recommendation 12: Discussion With Treating Team and Collateral Information
Recommendation 12(a) If the requester’s primary healthcare provider is not one of the assessors, assessors should obtain input from that person. When the requester’s clinical care is shared by members of a multidisciplinary healthcare team, assessors should solicit their input.
Recommendation 12(b) With a requester’s consent, assessors and providers shall obtain collateral information relevant to eligibility and capacity assessment. This should include reviewing medical records, prior MAiD assessments, and discussions with family members or significant others. Care must be taken to determine that obtaining collateral information will not be harmful to the requester.
Recommendation 13: Challenging Interpersonal Dynamics
Assessors and providers should be self-reflective and examine their reactions to those they assess. If their reactions compromise their ability to carry out the assessment in accordance with professional norms, they should seek supervision from mentors and colleagues, and/or discontinue involvement in the assessment process. The practitioner should adhere to any local policies concerning withdrawal from a MAiD assessment and onward referral.
Implementation
Recommendation 14: Consultations with First Nations, Inuit and Métis Peoples
Consultation between health regulatory bodies in each province and territory with First Nations, Métis, and Inuit peoples must aim to create practice standards with respect to MAiD MD-SUMC, and MAiD more generally, that incorporate Indigenous perspectives and are relevant to their communities.
Recommendation 15: Training of Assessors and Providers in Specialized Topics
To support consistent application of the law and to ensure high quality and culturally sensitive care, assessors and providers should participate in training opportunities that address topics of particular salience to MAiD MD-SUMC. These include, but are not limited to: capacity assessment, trauma-informed care and cultural safety.
Recommendation 16: Prospective Oversight
Given its concurrent jurisdiction in relation to MAiD, the federal government should play an active role in supporting the development of a model of prospective oversight for all or some Track 2 cases that could be adapted by provinces and territories.
Recommendation 17: Case-Based Quality Assurance and Education
The federal government should play an active role in supporting the development of provincial/territorial systems of MAiD case review for educational and quality improvement purposes.
Recommendation 18: Modifications to Data Collection Under the Federal MAiD Monitoring System
Data related to specific topics (eligibility, supported decision-making, means available to relieve suffering, refusal of means available, and residence and legal status) should be collected in the MAiD monitoring system in addition to data already collected under the 2018 Regulations. These data can be used to assess whether key areas of concern raised about MAiD MD-SUMC and complex Track 2 cases discussed in this report are being addressed by the clinical practices recommended.
Recommendation 19: Periodic, Federally Funded Research
The federal government should fund both targeted and investigator-initiated periodic research on questions relating to the practice of MAiD (including but not only MAiD MD-SUMC).