Unpacking the CPA's MAiD update before Thursday's AGM

After not having had any opportunity to provide input to the Canadian Psychiatric Association’s (CPA) 2020 Position on MAiD and mental illness, CPA members finally have a chance to bring forward Member Proposals on MAiD at the upcoming Nov. 25 CPA AGM. Interestingly, after refusing to make any changes despite facing 20 months of criticism from membership that its Position Statement on MAiD and mental illness failed to provide any evidence-based guidance, less than two weeks before the upcoming AGM CPA leadership released a “Position Statement Update” on Nov. 12. While CPA leadership had a chance to correct and improve the deeply flawed March 2020 Position Statement on MAiD, unfortunately the November 2021 CPA MAiD Statement Update not only fails to correct the serious flaws of the original 2020 Position Statement, in many ways it is even worse than the original Position. What has (and has not) changed? Most of the changes in the Update reflect the addition of historical information referencing the 2019 Truchon case and the passage of Bill C7. Of note, even though the Truchon ruling occurred in September 2019, flagging that MAiD would soon be expanding to the non-dying disabled by removal of the reasonably foreseeable death safeguard, CPA leadership did not reference Truchon in its initial March 2020 Position Statement six months after Truchon, nor did it reference Truchon or provide this context in its October 2020 member survey. Only now, two years after Truchon, eight months after the passage of Bill C7 in March 2021 (which expanded MAiD and introduced the sunset clause to ensure MAiD for mental illness will be provided by 2023), and two weeks before facing Member Proposals at the AGM, that CPA leadership is mentioning the impact of the Truchon ruling to members. Read: Why is access to medically assisted death a legislated right, but access to palliative care isn’t? Remarkably, like the initial 2020 Position Statement, the 2021 Update continues to lack any evidence-based guidance and continues to fail to cite a single clinical or evidence-based reference whatsoever. Even more remarkably, despite repeated concern being raised about CPA’s lack of mention or cautions regarding potential suicidality and mental illnesses in public policy consultations on mental illness and death, CPA leadership continues to refuse to include any cautions regarding mental illness related suicide risk, the importance of suicide prevention, or even use any word related to “suicidality” in its Position Statement Update. How is the Update worse than the initial Position Statement? Beyond its continued and disturbing lack of any mention of the word “suicide” (likely the most significant evidence-based issue related to mental illness and death in these consultations—imagine a respirologist association refusing to mention smoking as a risk factor for lung disease), CPA leadership has managed to make their Position Statement even more dangerous than the original. Not only does Declaration 2 of the Update continue to make no mention of evidence regarding predicting, or being able to predict, irremediability in mental illnesses, while still maintaining that, “Patients with a psychiatric illness . . . should have available the same options regarding MAiD as available to all patients,” it adds the phrase, “where eligibility requirements are determined to be met.” This implies, quite explicitly, that those requirements, including predicting irremediability of mental illness, can be met, despite all current scientific evidence to the contrary. Read: Fresh insights into Ontario psychiatrists' views on MAiD Declaration 5 of the Statement previously stated that as part of the eligibility assessment, psychiatrists were to be rigorous in “identifying symptoms of mental disorder that are likely to affect decision-making.” The “Update” released by CPA leadership removes the caution about assessing whether symptoms of mental disorder are impacting decision making, and replaces it with a requirement to identify “treatable symptoms of mental disorder.” While most psychiatrists would consider it common sense to identify treatable symptoms, it’s important to remember that Canada is the only jurisdiction in the world where patients can get MAiD even if standard practice treatments have not been tried. Given that patients can qualify for MAiD even if their suffering could be relieved by non-invasive standard treatments, but the patient does not consider them “acceptable,” and further given that our patients’ decision-making can be impacted by symptoms of mental disorder even while they retain legal capacity, CPA leadership’s conscious decision to remove the specific expectation of needing to identify mental illness symptoms that are likely to affect decision making is both puzzling and disturbing. Declaration 4 of the Statement previously stated that psychiatrists must provide “information regarding available MAiD resources and the referral process.” In the Update, CPA leadership has changed this to require psychiatrists to provide “an effective referral.” Given many members have expressed concern about the continued lack of evidence in being able to predict irremediability in mental illnesses, it is unclear what the ethical and legal tensions will be when psychiatrists are forced to provide “effective referrals” when they know those will go to other psychiatrists who unscientifically and wrongly believe they are able to predict irremediability of mental illness. Concerning implications and false neutrality As mood and suicidology expert Dr. Mark Sinyor recently pointed out in his Grand Rounds at Sunnybrook Hospital, what happens when family members sue a psychiatrist or hospital for providing MAiD for a supposedly “irremediable condition,” when all evidence to date indicates we cannot predict irremediability of mental illnesses in any scientific or reasonable way? For that matter, what legal liability might fall upon medical associations that have repeatedly failed in their duty to raise evidence-based concerns and provide evidence-based guidance in policy consultations? Read: Lessons from the MAiD debate: Medical associations should give evidence-based input, reflect diverse member views What about CPA leadership’s continued claim of “not taking a position” on MAiD for mental illness? This claim stretches the bounds of credulity. By never raising the issue of the need for evidence in determining whether mental illnesses can be predicted to be irremediable (indeed, acknowledging they have not even examined the issue), while repeatedly saying it is discriminatory for patients not to be able to get MAiD for mental illness and now explicitly implying eligibility requirements (including determination of predicting irremediability of mental illness) can be met, CPA leadership has taken a position. Others have written about how medical organizations claiming to be “neutral” and "to not be taking a position” on assisted dying expansion is problematic, and sometimes even a disingenuous dog whistle providing tacit approval of expansion of assisted suicide policies. As Aaron Kheriaty writes, “A closer look at the recent rash of legalization of assisted suicide in several states and countries shows that doctors’ own medical associations actively helped to pave the way, all while ducking behind a disingenuous guise of merely staying neutral.” Moving Forward Finally, as I have written elsewhere, CPA leadership’s continued blanket claim that it is “discriminatory” not to provide MAiD for mental illness, when that suffering can be remediable and is often social suffering fueling suicidality, is tone deaf to the evidence, culturally insensitive, and comes from a position of colonial privilege. And it seems stakeholder groups across the country agree. From our national suicide prevention organization CASP, to indigenous leaders, to experts in Assertive Community Treatment Teams providing clinical care to our most seriously mentally ill, to disability advocates, to legal experts, stakeholder groups across Canada have denounced CPA’s Position on MAiD and are calling on CPA leadership to change its Position. Read: MAiD expansion poses greater dilemma for many physicians Unfortunately, CPA has so far resisted all efforts to modify its Position, adopted by a small group in key leadership positions. If CPA is to adopt an evidence-based position, rather than continue its current policies, which place patients, organizational credibility, and member (and potential organizational) liability at risk, it looks like it will be up to members to continue to overcome uphill hurdles and hopefully force positive change at the Nov. 25 AGM. If you are a CPA member, make sure you register beforehand and have your voice heard. 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 Dr. Gaind's views are his own and do not represent the views of The Medical Post or its parent company.

Unpacking the CPA's MAiD update before Thursday's AGM

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