Medical Assistance in Dying and Suicide

Medical Assistance in Dying (MAID) has been described as an ethical quagmire which no legislation can address perfectly.  This is because the practice puts into conflict the dual societal virtues of respecting personal autonomy and the need for robust suicide prevention efforts and messaging.  Expert bodies in the latter, such as the American Association of Suicidology[1], have stated that MAID and suicide can, at least in principle, be distinguished but also underscores the potential for “overlap” cases.

The concept of overlap is helpful in framing the discussion as the risk is likely to vary dramatically.  For example, there may be little to no overlap between MAID and what we traditionally understand as suicide in those people seeking MAID at the end of life.  In contrast, the risk of overlap increases precipitously for those seeking MAID for chronic, non-life threatening conditions and, in particular, for mental disorders.

The Canadian Association for Suicide Prevention (CASP) acknowledges the importance of respecting the autonomy of the individual and affirms that Canadians (deemed capable to make such decisions) ought to be able to access MAID to exert control over a death process that is already happening.  At the same time, efforts to prevent suicide including healthy messaging across society mean that we must work towards a future where no Canadians use death as a remedy for a difficult life.

As a suicide prevention organization, we envision a Canada without suicide. Through advocacy, communication, and education, we aim to prevent suicide and support individuals, families, groups, and communities impacted by suicide. We recognize that chronic medical and mental health conditions as well as existential suffering can feel unbearable and that for some people in these circumstances ambivalence may be a feature of daily life.  We know that in the space of ambivalence, it can be challenging to hold onto hope; nevertheless, CASP aims to nurture and cultivate sparks of hope, even in the darkest places.  Our core values as an organization are Leadership, Inclusivity, Fairness, and Excellence, and when taken together, these values clearly demonstrate our commitment to LIFE. 

 

Areas of Concern/Informing the Dialogue

Given current and anticipated legislative challenges aiming to expand the scope of MAID in Canada to those people with chronic, non-life threatening illnesses including mental disorders, CASP wishes to highlight the following considerations to inform the courts and for inclusion  in the broader national dialogue.

We are aware of strong positions that have been taken by various mental health and MAID advocacy organizations regarding the potential remediability of mental disorders.  Specifically, the Canadian Mental Health Association has released a position paper on MAID stating that mental illness can be grievous but is never irremediable (as required for MAID eligibility in Canada)[2].  In contrast, MAID proponents have taken the position that mental disorders are 

definitively irremediable in some cases.  It is important to note that neither stance is evidence-based.  Studies of psychiatric care generally examine the impact of a narrow set of treatments to address symptoms of specific disorders rather than whether offering all treatments available has the potential to remediate both suffering and improve function in all patients.  For example, the STAR*D trial was among the largest clinical trials ever conducted.  It examined treatment of depression in nearly 3,000 people over one year.  However 94% of subjects received only  medication and nearly 40% of subjects were treated by their family physician rather than a psychiatrist.  Such studies are wholly unsatisfactory in answering the question of remediability.  The most scientifically accurate interpretation of the present research literature is that, in the context of limited or inadequate care, a small proportion of mental disorders may appear irremediable with no clear indication of whether this is actually so.

 

With that said, there are several important concerns relating to suicide in the context of MAID expansion to those not at the end of life[1]

1. A life worth living:  While our core mission will always focus on preventing suicide, we believe that it is not enough for a suicide prevention organization to merely stop people from dying— it is imperative that Canadians invest in finding other ways to alleviate suffering and support people in connecting to a life worth living.  MAID, as it currently exists in Canada, is in no conflict with this approach since it is used to remedy painful deaths.  However, expansion of MAID to include those not at the end of life carries the inherent assumption that some lives are not worth living and cannot be made so.  This notion is controversial, in inherent conflict with suicide prevention and has several potentially negative implications outlined below.
2. Suicide messaging and contagion: There is a large literature demonstrating that both suicide and coping/help-seeking are contagious.  Sending a message that sometimes death is the best remedy for a painful life is likely to subvert suicide prevention messaging, one of the few population-level interventions know to decrease suicide rates[2]. 
3. Shifting social norms: Dutch MAID providers have expressed concerns that people in the Netherlands are now accessing MAID as a solution to an increasing number of problems and that the public in that country are viewing the practice as normal and even easy when they consider it extraordinary and difficult.  From a suicide prevention perspective, it is important that MAID be understood as an unusual and extraordinary option to avoid a social norm in which death is considered a common coping strategy.
4. Duty to die:  Shifting norms also have the potential to create social pressure or a so-called “duty-to-die” for people with chronic illnesses who may seek death as a way to alleviate the burden that they perceive they are causing others.  Such a norm is again in conflict with suicide prevention efforts aimed at helping people challenge and reject thoughts that they are a burden in favour of efforts to see their positive role in the world.
5. Mental healthcare: Finding hope and reasons to live are a quintessential aspect of clinical care in mental disorders.  Having MAID as a treatment option is in fundamental conflict with this approach, is likely to have a negative impact on the effectiveness of some therapeutic interventions and may lead both patient and provider to prematurely abandon care.
6. Psychiatric policy: To some extent, the same issues that arise in the clinician’s office apply at the macroscale.  Ending the life of someone with complex health problems is simpler and likely much less expensive than offering outstanding ongoing care.  This creates a perverse incentive for the health system to encourage the use of MAID at the expense of providing adequate resources to patients and that outcome is unacceptable

CASP believes that we need to consider the broader context of suicide prevention and life promotion for all Canadians.  This is a critical time to address gaps in our knowledge, resources, and supports that are necessary to accomplish our vision of a Canada without suicide.  If we want to take suicide prevention seriously, we must attend to the structural and systemic changes necessary to increase access to a life with dignity.   Below are recommendations to help facilitate that process.

With that in mind, we offer the following considerations:

 

Recommendations

1. Given that MAID and suicide can overlap and that MAID-related public messaging may interfere with safe suicide messaging, the government and courts must take great care to include concerns about suicide into any legislative changes related to MAID.
2. The lack of proper scientific evaluation of the impact of MAID on suicide rates also deserves attention and, given potential harms, should be corrected by researchers in the area.
3. Given that inadequate care may cause remediable illnesses to appear irremediable, it is of vital importance that that government and policymakers undertake efforts to improve access and treatment of mental disorders across Canada.  The anguish, pain, and suffering that result from some severe mental health conditions are as real and legitimate as those resulting from a physical health condition and must be addressed through the following efforts:

1. Increase availability of and access to services, including investment in resources to reduce wait times for appropriate and effective services and investment in treatment options particularly for people experiencing chronic and severe suicidality.
2. Improve funding for research to understand which sequence and/or combination of treatments are most optimal for specific conditions and symptom profiles.
3. Improve funding for treatment to ensure a wider variety of options are available for people needing support.
4. Support widespread training in compassionate patient-provider conversations about mental health conditions and options for alleviating suffering.
5. Increase training for providers, particularly in evidence informed approaches to treatment.

1. Regardless of whether legislation changes, there is a need for further national dialogue about preventing suicide and promoting life which requires policymakers to:
1. Prioritize the implementation of the national strategy for suicide prevention and life promotion.
2. Support communities in responding to people who are impacted by suicide with strategies aimed to reduce stigma and promote connection, community, and belonging.

[1] Note that legislation could aim to minimize these harms but will be unable to mitigate them entirely.  That is, harm will occur, it is only a question of degree.

[2] The impact of MAID legislation on actual suicide rates is of crucial importance in evaluating the potential for harm.  Unfortunately, high-quality, rigorous scientific studies accounting for other factors that may influence suicide rates are virtually absent from the scientific literature.

[1] https://suicidology.org/wp-content/uploads/2019/07/AAS-PAD-Statement-Approved-10.30.17-ed-10-30-17.pdf

[2] https://cmha.ca/wp-content/uploads/2017/09/CMHA-Position-Paper-on-Medical-Assistance-in-Dying-FINAL.pdf