Medical Assistance in Dying (MAID) became legal in Canada in June 2016.
In October 2020, Bill C-7: An Act to amend the Criminal Code (medical assistance in dying) was introduced in Parliament after it was determined that limiting access to MAID to those whose death was ‘reasonably foreseeable’ was unconstitutional. MAID was on its way to becoming an option for those whose only medical condition is a mental illness.
In August 2021 the federal government established an Expert Panel on MAiD and Mental Illness. The Panel was charged with the task of “making recommendations on protocols, guidance and safeguards to requests for MAID by persons who have a mental illness”.
The Expert Panel released their final report, which was tabled in Parliament in May 2022. Dr. Jeffrey Kirby, a bioethicist, was one of the Expert Panel Members (until he resigned in April 2022). On October 2nd I had the pleasure of speaking with Dr. Kirby.
After reading the Expert Panel’s Final Report and speaking with Dr. Kirby, it seems apparent there are some significant issues that have yet to be addressed. Among the concerns is the biased perspective held by the Panel as a whole.
When describing the Panel membership, the Government of Canada states: “Members of the Expert Panel on MAID and Mental Illness reflect a range of disciplines and perspectives, including clinical psychiatry, MAID assessment and provision, law, ethics, health professional training and regulation, mental health care services, as well as lived experience with mental illness.”. The Expert Panel does indeed include a broad range of professional disciplines and lived experience expertise. However, member bios reveal an obviously dominant biomedical perspective. And although it was not the Expert Panel’s task to debate whether those whose only medical condition is a mental illness should be eligible for MAID, the Final Report will be used in a variety of settings, and will likely influence policy and practice. With this in mind, the dominance of the biomedical perspective is a red flag on this Final Report.
Central to the biomedical narrative is the notion that mental illnesses are biologically based medical conditions. It’s worth noting here that psychiatry’s ambivalence about the biomedical narrative, that is essential to upholding its legitimacy as a subspecialty of medicine, can be seen in more than a few places within the DSM-5-TR (published by the American Psychiatric Association in 2022), including:
“Since a complete description of the underlying pathological processes is not possible for most mental disorders, it is important to emphasize that the current diagnostic criteria are the best available description of how mental disorders are expressed and can be recognized by trained clinicians.” (Preface to DSM-5, included on p.xxiii of DSM-5-TR)
“In the absences of clear biological markers or clinically useful measurements of severity for many mental disorders, it has not been possible to separate normal from pathological symptom expressions contained in diagnostic criteria.” (Use of the Manual, Clinical Significance Criteria, p.23, DSM-5-TR).
Despite the uncertainty admitted by psychiatry’s highest office of representation, the biomedical framework continues to be the dominant perspective within most mental health care settings in Canada, and most other developed nations. Because this perspective is clearly dominant within the MAID and mental illness Expert Panel, it’s important to name this elephant in the room.
Within this biomedical perspective is the belief that ‘mental illnesses’ are permanent medical conditions. If an individual is lead to believe their interminable suffering is the result of a permanent medical condition, they might also come to believe there might never be an end to their suffering. Although this line of thinking is certainly more layered and complex than what can be unpacked here, it should be apparent that telling someone they have a serious, lifelong medical condition will influence decisions they make about their future.
When viewed through a critical lens, it becomes easy to see the problematic nature of any decisions that could be made based on this biased point of departure. When considered in the context of MAID for mental illness, this begs the question, ‘should there not be more disturbance at the thought of vulnerable people basing their decision to access MAID on a heavily biased, and scientifically unproven biomedical narrative?’.
The date when those who are suffering solely from a mental illness can access MAID in Canada is March 17, 2024.
Through the information and concerns shared by Dr. Kirby, it will be apparent that there are a number of other issues and gaps in understanding that have yet to be addressed.