Thank you for the opportunity to be here today. My name is Alison Freeland. I am a psychiatrist, and I'm here in my capacity as chair of the board of directors of the Canadian Psychiatric Association and co-chair of the CPA's MAID working group.
Today I will focus my remarks on medical assistance in dying as it pertains to requests on the sole basis of a mental disorder to supplement the CPA's brief that was submitted to this committee a few weeks ago.
The CPA has not taken a position on whether MAID should be available where mental illness is the sole underlying medical condition. However, we do believe that any new legislation must protect the rights and choices of all vulnerable Canadians without unduly stigmatizing and discriminating against those with mental disorders where eligibility requirements are determined to be met.
In considering safeguards, the CPA discussion paper looked at the issue of capacity. A mental disorder does not in and of itself imply incapacity in any domain of decision-making, but when active, various forms of mental illness can impair decision-making and capacity. Psychiatrists have specialized training and expertise in the assessment, diagnosis and treatment of mental illnesses, including the assessment of decisional capacity as well as the durability, stability and coherence of a person's expressed will and preferences. Psychiatrists are well versed in taking into consideration any external constraints or internal psychopathology that may impact these issues.
Inequities of service provision and funding are an issue for all types of conditions. This is an area that is particularly problematic for people living with mental illness. Such inequities are further exacerbated for people who live in rural or remote areas. Whether the illness is physical or mental, or a combination of both, equitable and timely access to evidence-based, culturally appropriate clinical services is a first and essential safeguard to ensure that people do not request MAID due to lack of available treatments, supports or services.
In the context of mental disorders, there is no generally agreed definition of incurability. Within the field of psychiatry, there are some who do not accept that any mental disorder isn't curable and will argue that there is always another treatment to be attempted. Resolution of this issue requires a pragmatic approach that balances clinical expertise and assessment of incurability with the patient's perspective and experience of their illness.
Socio-economic determinants of health, which play a key role in each person's experience of suffering and adaptability to mental illness, are important to consider. If a patient refuses recommended treatment for their disorder without good reason, weighing both the potential benefits and burdens, they are unlikely to have met the eligibility criterion for incurable.
Vulnerability is not limited to those with mental illnesses. Many people with non-psychiatric illnesses are also vulnerable because of such psychosocial circumstances as isolation or poverty, cognitive distortions and demoralization due to failed treatment attempts or difficulty in adjusting to life with their illness. The trajectory of physical illness can be as unpredictable as that of mental illness. Loss of hope can occur, as can spontaneous remission. Predicting treatment outcomes is as much a challenge for psychiatry as it is for the rest of medicine.
Both acute and chronic suicidal ideation must be considered and evaluated to make a best determination as to whether the patient's wish to end their suffering represents a realistic appraisal of the situation, rather than a potentially treatable symptom of their mental illness. A request for MAID should be considered and sustained, and not be the result of a transient or impulsive wish. This is particularly important for persons with non-terminal conditions, such as a mental disorder where illness maybe more episodic in nature.
Therefore, separate from any MAID eligibility assessment, it is essential that at least one independent psychiatrist completes a comprehensive clinical assessment to validate whether the patient has received an accurate diagnosis and access to evidence-based mental health assessment, treatment and supports for an adequate period of time based on generally accepted standards of care.
Thank you very much. I'd be happy to try to answer your questions.