And now for something completely different

Having recently re-watched the remastered 4K extended edition of the Lord of the Rings, I’m struck by how life mimics art, and how time can bring increased clarity even while repeating the same story. In March 2020, I wrote the most difficult article of my career, critiquing my national specialist association, the Canadian Psychiatric Association (CPA) of which I am a past president, for its deeply flawed Position Statement on Medical Assistance in Dying (MAID) released after two years of zero member engagement on the issue. I also wrote to my colleagues on the CPA Board urging them to reconsider the process and content of the Statement, hoping for collegiality and urging them “to resist the simple ‘circling the wagons’ and projective blame dynamics that a public challenge to a group’s actions often precipitates.” I concluded my letter to my Board colleagues stating: “In my mind, this will reveal the character of the CPA—it is a choice between honest self-reflection and integrity, or reflexive loyalty and standing by a mistake. I have already made up my mind on where I choose to fall on that spectrum, difficult as the decision is.” It’s unfortunate how prescient those words have proven to be. A recap of my journey After my public critique of the CPA’s process and letter to the board in spring 2020, the CPA responded by revoking my previously submitted nomination for a second term on the World Psychiatric Association Board. Read: Nova Scotians seeking MAiD will soon have 'oral option' to self administer Then in March 2021, after I publicly indicated I was considering running for CPA president-elect again, the CPA Board revised election policies in the middle of an already open election nomination process, without notifying members. It was not till August, over four months after my nomination had been submitted and nominations closed, that the CPA informed me I was ineligible to run for president-elect since CPA rules now precluded a past-president from running for that position again (more bizarrely, two months earlier in June the CPA had me sign a new “conflict of interest” form ostensibly as part of the nomination process, despite the fact I had already been rendered ineligible to run without my knowledge). With my disqualification, there was only one remaining candidate, who was acclaimed as CPA president-elect without any election. Now, in February 2022 the new CPA chair informed me that the old CPA Board voted three months previously, on Nov. 1, 2021, to recommend my suspension as a CPA member. The rationale cited was my “unprofessional” conduct, and my “public comments which misrepresented CPA processes and governance matters, and were damaging to the reputation of the organization,” without providing any actual such examples. I am waiting to hear back from the chair regarding the new Board’s final decision, given I have always conducted myself with professionalism, accuracy and integrity, notwithstanding the actions of others. In terms of any potential “reputational damage” to the CPA, that certainly has not been through any misrepresentations on my part. Impact on MAiD policy Beyond my painful experience, how has the CPA continued to influence evolving policies on MAiD? My November 2021 piece discussed the upcoming CPA AGM and several Proposals on MAiD members had submitted. While the AGM outcome was not satisfying, it was revealing. In the end, the key Proposal, which would have required that CPA policy on MAID include guidance on, “the need for evidence and standards.” and to ensure that MAID was “not requested as . . . a response to psychosocial stressors or a death of appropriate clinical and community supports,” was, remarkably, not passed. Read: Fresh insights into Ontario psychiatrists' views on MAiD Yes, you read that right. CPA has now explicitly rejected Member Proposals that sought evidence and standards to guide CPA policy, and that sought to ensure death by MAID was not provided for social suffering or lack of access to care and supports. If I had not heard it myself, I could never have imagined CPA leadership would speak against these Proposals. Here is the exact wording of the Proposal that CPA leadership spoke against: Given that MAiD is based on the premise of having an irremediable medical condition, that any CPA policy on MAiD explicitly include guidance on: (i) the need for evidence and standards regarding whether or not mental illnesses can reliably and prospectively be determined to be irremediable medical conditions, prior to any potential consideration of MAiD being provided for sole psychiatric conditions; (ii) the need for appropriate treatments having been tried, and supports and services being in place, to ensure that MAiD is not requested as a means to escape social exclusion, nor as a response to psychosocial stressors or a dearth of appropriate clinical and community supports. Kafka lives The vote was deadlocked, 41 to 41, and the motion failed. I learned after the vote that at least one member who wanted to vote “yes” advised the CPA prior to the vote that the CPA’s virtual meeting was preventing them from casting a vote, with no follow-up or resolution. As far as I am aware, the CPA has not even communicated an update regarding the AGM to members in the over three months since the AGM. You can’t make this stuff up. In a country with over 4,000 psychiatrists, with fewer than 2,000 being CPA members, the policy guidance being offered by my national psychiatric association has now formally rejected “the need for evidence and standards” and “the need for appropriate treatments having been tried” before offering MAiD for mental illness, based on less than 1% of Canadian psychiatrists voting against this at the CPA AGM. Read: Lessons from the MAiD debate: Medical associations should give evidence-based input, reflect diverse member views Moving forward For the past two years, I and others have tried to engage with CPA leadership to improve processes and ensure policies impacting our patients are evidence-based. While I am aware former CPA members have resigned over CPA processes, I continued to try to engage despite the significant personal toll it has taken. Despite my best good faith efforts, that has clearly failed. So, back to Lord of the Rings. While I believe it’s misguided for the CPA Board to suspend me (quite remarkable really, I recall no other member suspension during my extensive time with the organization), their willingness to use their authority to do so is strangely liberating. Just like Frodo must have felt once freed of the Ring (albeit with Gollum’s unwitting assistance), there is a certain freedom that comes from realizing something no longer holds power over you. While I await the Board’s final decision regarding my suspension, I realize a decision to suspend will more “reveal the character of the CPA,” as I wrote two years ago, rather than be any reflection of me. At this point the CPA has made itself irrelevant to my professional identity. More importantly, these experiences have highlighted for many the dire need for a national organization that engages members, is transparent, and provides credible evidence-based guidance to inform health policy. Fortunately work has been underway with peers and colleagues for some time on how to fill this need. Every good ending needs a better beginning. Two years ago, after the CPA suddenly released its Position Statement on MAiD, I started my first piece in this series saying I wish I didn’t have to write this. One year ago, I concluded another piece here with, “Canadian psychiatrists deserve an association that does solicit and represent their views, and it is hard setting up new organizations.” Today, I am thrilled to be able to announce that in two months, on May 11, 2022, a new national society, the Society of Canadian Psychiatry, will be launched. Any interested can watch the countdown and get more information here. It will be something completely different . . . Dr. Karandeep Sonu Gaind is a professor at the University of Toronto, an Honorary Member of the World Psychiatric Association and a former president of the Canadian Psychiatric Association. Twitter: @Psych_MD

And now for something completely different

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