Thank you for the opportunity to provide my perspective.
I'm a physician with 14 years of tertiary experience in emergency psychiatry involving suicidality, and I'm a researcher, teacher and expert in suicide and suicidology.
It's really important to note that what most people think of as suicide is far different from most experiences of MAID. I've submitted a brief regarding many of the myths comparing suicide to MAID, and I trust that it's been helpful to the committee. I'd like to draw special attention to three of the points that I made.
First, motivations in MAID and suicide are rarely the same. In suicide, it's very rare to have a combination of fatalistic motivation, which is a controlled response to a perceived stress, an agreed-upon lack of remedy and a rational calculation of the likelihood of change, whereas in MAID this is almost always the case. In the literature, psychiatrists generally agree with the patient's unbearable suffering and futility of treatment in psychiatric MAID cases in the countries where this has been studied.
Second, the wish to die is not indicative of a mental illness. While depression does include suicidality as one of its nine criteria, the presence of a serious mental health diagnosis is absent in 40% to 50% of all who die by suicide. Many who experience suicidal thinking do not have a diagnosable mental illness, and the vast majority do not die by suicide.
Third, capacity assessments are a core part of psychiatric training. This is probably the most achievable and least controversial aspect of these discussions and not an area of significant controversy in psychiatry.
To the larger complex question regarding psychiatric MAID, I'm comforted by an approach that helps me in my clinical life. You see, most of my patients are sent to me as a tertiary psychiatrist when other psychiatrists and doctors are seeking care and expertise for a complicated case. Where other physicians who deal with primary presentations follow guidelines or algorithms, I rarely have an algorithm to follow. In fact, the book of algorithms for my line of work would be minuscule.
Rarely do I ever have a perfect answer. For this, I both teach and practise science-based medicine and principle-guided medicine. For science-based medicine, we use the best evidence we have at the time. We apply plausibility in expertise and recognize the importance of updating our information as new, excellent information comes to light.
In this regard, there are decades of experience of MAID in some countries and some with psychiatric MAID, and it suggests that it's well practised, well accepted and represents only a small fraction of all MAID deaths, 1% to 2%. Given the number of people with suicidal thinking, there is simply no credible foundation for the fear that allowing MAID for psychiatric conditions would create a flood of deaths in Canada.
One study estimated suicidal thinking as an 8% lifetime risk for adults in the Netherlands, yet 65 or 0.0004% of adults in the Netherlands have died of MAID in any given year due to psychiatric reasons.
Adding the procedures that should be in place for MAID, the plausibility of a hasty, poorly thought out conclusion regarding MAID is drastically reduced. I've also submitted evidence regarding a review of studies of psychiatric MAID in various countries to the committee.
For principle-guided medicine, one uses a set of principles to dictate decision-making. There are many principles that I consider when it comes to psychiatric MAID. First, we must respect the autonomy of our patients, especially when we have determined that they have the capacity to make decisions for themselves.
Second, we must be cognizant of systemic racism, systemic ableism and lack of access to mental health care in Canada. It should never be that someone chooses MAID due to a system that inflicts racism or ableism on that person or limits their ability to access quality mental health care.
Third, we must not discriminate against people with mental illnesses nor discriminate against those with psychological suffering.
Fourth, not all conditions respond to treatment. No treatment in psychiatry has a 100% cure rate, and psychiatry has been loathsomely slow compared with other specialties to the medical notion that some people do not, for a variety of reasons known and unknown, respond positively to treatment. For some, treatment is a miserable experience with no benefits.
Fifth, psychiatry has a long legacy of paternalism, and decisions must be centred in a place where the expertise of physicians and those with lived experience overlap. Finally, only a physician's professional opinions, not their personal beliefs, should exert influence on a patient in their health care decision-making.
I can imagine a system in Canada that honours the best science and principles we have regarding this issue and, for that reason, I'm cautiously but generally supportive.
Thank you.