Thank you, Mr. Chair. I'll start for us.
On behalf of the Canadian Psychiatric Association, we'd like to thank the co-chairs and committee members for this opportunity to present to you on this important issue.
My name is Karandeep Sonu Gaind, and I'm president of the CPA. The CPA is the national voice for Canada's 4,700 psychiatrists and more than 900 psychiatric residents. Founded in 1951, the association is dedicated to promoting an environment that fosters excellence in clinical care, education, and research.
My remarks today will focus on specific issues related to mental illness that must be considered in any physician-assisted death framework. The CPA is actively engaged in developing a full position with a range of specific recommendations. My comments today are meant to raise key points for the committee to consider in its deliberations, but should not be construed as CPA's final position on this issue. That definitive position is still being developed.
I'll start with key issues that need to be taken into consideration when discussing terms like “irremediable”, “intolerable and enduring suffering”, and “capacity” in the context of mental illness.
The evaluation of what is intolerable and enduring suffering due to illness symptoms is affected by the severity of those symptoms and impairment and by the individual's perception of their experience. The subjective assessment of “intolerable” and the predictive assessment of “enduring” can both be affected by mental illness in particular ways.
Mental illnesses can affect cognition and impair insight and judgment. Symptoms of cognitive distortions common with clinical depression include negative expectations of the future; loss of hope; loss of expectation for improvement, even when there may be realistic hope for positive improvement; loss of cognitive flexibility; loss of future-oriented thought; and selective ruminations focused on the negative and minimizing or ignoring the positive. There are commonly distortions of a person's own sense of identity and role in the world, including feelings of excessive guilt and worthlessness or feeling like a burden to others.
When clinically depressed, people also have lower emotional resilience and are less capable of dealing with normal life stressors. They can experience even moderate levels of stress as being intolerable or overwhelming. While we are not at the point of being able to apply this clinically, increasingly research findings are suggesting that there are areas of the brain with altered functioning during times of severe depression that correlate with some of these cognitive changes.
In terms of what is “irremediable”, careful consideration needs to be given about what this means in the context of mental illness. Irremediable, of course, cannot simply mean incurable. Many conditions in psychiatry and medicine are considered chronic and not curable, but things may be done to remediate or improve the situation. Multiple treatment options exist typically for even the most severe instances of mental illness, whereby symptoms and suffering may be treated and reduced, even if not cured.
It is equally important and essential to remember that the person is more than the illness. Psychosocial factors play an enormous role in a person's illness experience, particularly so in many mental illnesses. For example, if you take an overly narrow view of assessing “irremediable” only in the context of potential symptom improvement through biomedical treatments in severe depression, you potentially ignore remediating or improving the person's experience by addressing such key factors as social isolation or poverty.
I'll make some comments on “capacity” now.
In medicine we consider four broad components when assessing capacity: the ability to make a choice, the ability to understand relevant information, the ability to appreciate the situation and the consequences of decisions, and the ability to manipulate information rationally. Even when persons with mental illness can express a choice and understand and recall information, their appreciation of the situation and of present and future expectations, as well as their ability to manipulate information rationally, can be affected by the cognitive distortions previously discussed.
I want to emphasize that none of this is to suggest that simply the presence of any mental illness alone impairs people's judgment and cognition, but in the PAD discussion, by definition, we are talking about the most severe situations, and in severe cases of mental illness, the risk of such cognitive distortion is, of course, higher. We think with our brains, not with our hearts or limbs.
All these issues speak directly to the court's concern about ensuring the person is not induced to take his or her life at a time of weakness. Apart from the actual suffering caused by symptoms, if cognitive distortions are present, these distortions risk undermining the person's decision-making process. In the court's consideration of factors of coercion or duress, it would be as if the mental illness is undermining the person's autonomy to make a decision free from the influence of cognitive distortions. It's this recursive effect of symptoms on the evaluative process, where the very symptoms of mental illness may interfere with people's evaluation of their mental illness and its present and future impact, that poses the challenge.
Finally, one other point bears consideration. In the context of the court's finding of loss of liberty if a person chooses to end his or her life prematurely because the person fears eventually becoming unable to take their life in the face of progressive physical incapacity and suffering, mental illnesses on their own very rarely, if ever, lead to such progressive and severe physical incapacity.
With that as a general background, and again emphasizing that the full CPA position is still being developed, there are a few guiding principles we can offer at this time.
First, when a psychiatric illness is present, in order to ensure that nuanced issues that could affect decision-making are properly assessed and to allow for time for potential remediation of symptoms and/or psychosocial factors, multiple assessors with suitable skill sets should do sequential assessments over a period of time. Our final position will reflect more specifics, and there may be varied mechanisms depending on jurisdictional needs and resources, but spreading the assessment over multiple suitable assessors who are aware of the potential impact of mental illnesses on cognition, capacity, etc., and also having sequential assessments are necessary safeguards.
Second, the concept of irremediable and intolerable and enduring suffering should not be exclusively focused on the biomedical condition but must be considered in the full context of the person's condition, including the potential impact of possible psychosocial interventions on suffering and symptoms.
Next, psychiatrists may choose not to be involved in the PAD process, consistent with what you have heard from other professional organizations. In such situations, patients requesting PAD should have access to information regarding available PAD resources and the referral processes, including psychiatric resources as required.
Finally, it is important to recognize that the term “treatment-resistant depression” or “treatment-resistant mental illness” in general does not define an illness that is irremediable. “Treatment-resistant” in this context is typically used to help guide the course of further treatment options using an evidence-based approach. This should be explicitly articulated in any PAD framework to avoid risking conflation of the terms “treatment-resistant” and “irremediable”.
I'd like to end by thanking the committee once again for your thoughtful consideration of these issues, and I'm happy to answer any questions that you may have.