Introduction

Webcast archive: The CCA Reports – Part IV – Mental disorders

Today, we finish our series on the Council of Canadian Academies papers by looking at the discrimination involved in promoting death for people with psychological conditions.

Webcast archive: The CCA Reports – Part IV – Mental disorders

In this episode of Euthanasia & Disability, Amy Hasbrouck, Christian Debray, and Taylor Hyatt discuss:

  • The CCA Reports – Part IV – Mental Disorders

Please note that this text is only a script and that our webcast contains additional commentary.

THE CCA REPORTS: SOMETHING ABOUT US WITHOUT US – PART IV: MENTAL DISORDERS

  • Today we present the last in our series on the Council of Canadian Academies report: the one on assisted suicide and euthanasia (AS/E) where a mental disorder is the only medical condition causing the request.  This was undoubtedly the most complex, interesting and difficult of the three reports.
  • A note on terminology; the report uses an abbreviation for the phrase “Medical Assistance in Dying for Mental Disorders as the Sole Underlying Medical Condition,” or MAID MD-SUMC, throughout.  In general, we try to avoid jargon, but we weren’t always able to work around the phrase and its abbreviation in the quotes.
  • It’s important to keep straight the different kinds of situations we’re talking about here:
    • A small number of people, who are involuntarily committed to a psychiatric hospital because they are a danger to themselves, are prevented from killing themselves;
    • Some people are discouraged from killing themselves via suicide prevention intervention (by hotline volunteers, therapists, and publicly-funded outreach programs);
    • Some people are being selected to receive help to kill themselves (or to be killed).
  • Another thing to keep in mind about the CCA reports is that they are discussing whether to expand the program before we even know how Medical Assistance in Dying is working in Canada.
    • On page 187, the report notes that the monitoring system (which went into effect on November 1, 2018) “is not intended to ‘assess … compliance with the Criminal Code exemptions.’”
    • The authors also mention the reports of Québec’s Commission on end-of-life care, but skip over the findings of those reports, which show that several people who were not eligible have already been euthanized.
  • Bill C-14 limits the Working Group’s mandate to situations where a mental disorder is the only reason for the AS/E request, without looking at how mental disorders affect the decision-making ability or interfere with the voluntariness of requests of people who are eligible because of a disability or terminal illness.
    • As we know, the stress of illness and disability, and the abuse, discrimination and barriers faced by disabled people, can trigger or worsen mental illness.
    • While we understand that the Working Group was unwilling to go beyond its legislative mandate, we believe that not exploring the impact of mental illness and physical disabilities together does a great disservice to the Canadian public.
  • One more point before we get to the details.  On page 68, the report says “Of course, a desire to die may also reflect a person’s autonomous and well-considered decision to end their life.” Starting this sentence with “of course” implies that everyone is in agreement about what you’re about to say. In fact, the idea that ending one’s life can be an “autonomous and well-considered” decision is only a theory (“rational suicide”) advocated by a few psychologists; it is not accepted in mainstream mental health practice.  The assumptions that underlie the theory – that having a disability is a fate worse than death and that suffering at the end of life is inevitable – have been consistently challenged by disability rights activists.
  • Honesty being the best policy; instead of “social” factors and hardships, the authors should say “discrimination.”
    • The report refers to “difficulty coping with social hardships,” (p. 41).  For example, they state that women are more susceptible to depression and anorexia in part because of gender-based violence.
    • The authors rightly point out that the relationship between “social factors” and mental disorders goes both ways; “social factors can increase a person’s risk of developing a mental disorder, and having a mental disorder can increase a person’s exposure and vulnerability to social factors that are detrimental to their mental health,” (p. 45).
  • The authors describe the (mis)treatment of people with psychiatric disabilities (pp. 46-47) concluding that: “the history of mistreatment of many people with mental disorders in the delivery of healthcare — the early asylums, the eugenics movement, the institutional abuses of the mid-20th century, and the failure to  provide sufficient resources following deinstitutionalization — demonstrates how such people could be vulnerable to further mistreatment” should eligibility for AS/E be extended to people with psychiatric disabilities.
    • The authors point out that “[p]eople with mental disorders have an increased risk of being the victim of crime, physical or emotional abuse, and sexual assault … face restrictions on their civil rights, and may be denied the opportunity to make decisions for themselves and manage their lives,” (p. 45).
    • On p. 80, the authors also say “Given the history of stigma and discrimination against people with mental disorders … there may be concerns that (i) someone’s decision to seek MAID might be due to stigma or the perception that people with mental disorders are burdens on families, and/or that (ii) families may pressure a person with a mental disorder to seek MAID.”  Unfortunately the authors don’t refer to the extensive historical information that supports this statement, but instead cite a single study from the Netherlands that seems to contradict it.
    • Later, the authors point out another potential problem; “some people may request [AS/E] because they cannot access or afford other mental health treatments that may reduce their suffering. This is a form of reduced voluntariness (i.e., lack of choice constrains voluntariness of choice)” (p. 166).
  • In Section 3.5, the Working Group examines the impact of psychiatric disabilities on “other specific populations,” looking at women, immigrant, racial and cultural groups, LGBTQ+, seniors, veterans, incarcerated people, and youth; in short, everyone but people with other disabilities.  What’s up with that?
  • The report is full of debate, on everything from the definition of terms like “impulsivity” and “intolerable”, to larger questions like whether suicide is a “free” choice.
    • “On the one hand, prohibiting MAID MD-SUMC may be seen as perpetuating paternalistic practices that restrict the civil liberties of people with mental disorders, and deny them freedom, choice, and autonomy.  On the other hand, permitting MAID MD-SUMC … may be seen as devalu [ing] people with mental disorders by suggesting that their lives may not be worth living and by promoting civil liberties without providing necessary resources,” pp. 47-48.
    • One faction recognizes the harms caused by discrimination and oppression, while another (neo-liberal?) faction seems to believe that a person’s choices should be considered “autonomous” even if a lack of services or supports impair their ability to make a free and informed choice.  This disagreement is re-stated several times, on different themes, in the report.  See for example, p. 172.
    • This reminds us of the policy in Oregon that says a person’s illness will be considered terminal even if the medication to treat it is not covered by insurance.
  • The authors note the “unique challenge in assessing decision-making capacity for MAID” in people with mental disorders:
    • The desire to die could be a symptom of the condition. Also, “[d]istorted perceptions of intolerability and irremediability (i.e., the belief that nothing can ever make a person feel any better) are common symptoms [of] some psychiatric” disabilities.  This is especially true for people with depression and personality disorders, who represent about half of those who were euthanized for psychiatric conditions in the Netherlands, (pp. 78-79)
    • This raises questions which are not really answered by the report, such as whether a person who is involuntarily committed to a psychiatric hospital under provincial law because they are considered a “danger to themselves” could be deemed eligible for assisted suicide.
  • The authors make an important point about the evaluation and treatment of suffering.
    • Usually, an assessment of a patient’s suffering is done to learn whether and how much suffering can be relieved.  But in the case of AS/E, where the person is on a path toward the goal of death, the suffering assessment must satisfy an eligibility criterion needed to arrive at the goal.  Any proposed treatment to relieve suffering may be seen as a barrier to achieving the goal of AS/E, and therefore be deemed “unacceptable.”
    • No other country allows the person’s own opinion of whether treatment would be futile, or what conditions of relief they would accept, to determine their eligibility under that criterion.
  • The discussion of suicide prevention in the report is based on the legal rule established in the Carter decision and Bill C-14 that there are suicides society will assist rather than prevent.  The “suicide prevention” discussion is really about how society chooses who gets help to live and who gets help to die, and how to re-defined “suicide” to make it not apply to people society wants to help to die.
    • The Working Group doesn’t challenge the “better dead than disabled” mindset because that is what drives the idea that some suicides should be assisted rather than prevented.
    • The authors claim that everyone involved in this selection process is neutral and even-handed, even down to suicide prevention hotline volunteers.  “In the view of these Working Group members, the only circumstance where suicide prevention interventions are not offered is when MAID is provided to someone who meets all requirements under C-14.”  It would be great if that were true, but that’s just not the experience of people with disabilities.
    • The Working Group quotes from the Suicide Prevention Framework; ““[p]eople experiencing thoughts of suicide … may feel hopeless or overwhelmed and see no other option.” This tends to discount real problems, like inadequate access to palliative care and being forced into an institution, that create hopeless situations, more than just feelings;
    • The report connects Bill C-14’s “concern for those who might end their lives in moments of weakness” only to impulsivity and ambivalence, not to the loss of resilience in the face of constant discrimination and barriers, (p. 86)
  • The Working Group asks whether the medical model of disability might contribute to how “suffering” is defined, especially for Autistics or people with intellectual disability, (p. 132).
  • The authors address, in passing, how feelings of the medical practitioner may affect their determination that the person’s mental disorder is treatable, that their suffering can be relieved, or other eligibility criteria.  A 1996 study “noted that 19% (13 cases) of psychiatric EAS were carried out ‘despite the consultant’s judgment that transference (i.e., patient’s redirected emotions from a past figure onto the physician) and countertransference (i.e., the physician’s emotional reaction to the patient) had influenced the decision-making’” (p. 138).
  • On pages 157-158 the authors talk about a therapeutic effect whereby “some … people who were approved for psychiatric EAS in Belgium withdrew their requests [because] knowing they had the option ‘gave them sufficient peace of mind to continue their lives’” but they don’t offer any alternative means for achieving that same effect, such as enabling the person to re-take control in their lives.
  • The Working Group proposes some safeguards that could be put into effect if AS/E were allowed for people with psychiatric disabilities.
    • Some of these are policies that should be in place anyway, such as:
      • Psychiatric evaluations for capacity;
      • Multi-disciplinary evaluation, to consider psychological, social or other non-medical factors that affect voluntariness and suffering; and
      • Mandatory reporting and case review.
    • Other possible safeguards:
      • Two-track approach, where one mental health practitioner assesses for AS/E eligibility while the other pursues treatment;
      • An extended waiting period of up to a year;
      • Requiring:
        • Agreement of a physician or mental health professional that treatment would be futile; and
        • That the person try reasonable treatment options (unless they can demonstrate “good cause” not to);
  • The “mental disorders” report has some good points; it raises issues of discrimination and barriers more than the other documents.  There is a lot of material here (the longest by 30 pages) yet there remained important questions that were beyond the scope of what the Working Group was supposed to cover.  We could only scratch the surface in our analysis, and we had to leave a lot out.  It’s obvious that some intense debates took place in crafting this report; that disability rights activists were not part of those discussions greatly reduces the value of the document.