Medical assistance in dying for mental illness: a complex intervention requiring a correspondingly complex evaluation approach: commentary, Breen

Response

The paper by Bastidas-Bilbao et al concerning the broadening of assisted dying criteria in Canada to include people with mental illness is worrisome.¹ The official figures for Medical Assistance in Dying (MAiD) in Canada are as follows: in 2022, there were 13 241 MAiD provisions in Canada, bringing the total number of medically assisted deaths in Canada since 2016 to 44 958. In 2022, the total number of MAiD provisions increased by 31.2% (2022 over 2021) compared to 32.6% (2021 over 2020).² These data speak for themselves. Extending this ‘programme’ despite all the complexities and ‘safeguards’, and deep-diving into extensive consultations with everyone, and modelling of diverse outcomes will serve to increase the numbers. This is choreographed window dressing to dis-inform us and distract from the substantive issue of whether extending MAiD should be considered at all. World experience shows that once assisted dying is introduced, these fine ‘safeguards’ recede, and what was once an exceptional highly regulated procedure becomes established medical practice for whoever wants it.³ Netherlands, Belgium and Canada in particular show this.

Every mental health professional knows that we work with a very vulnerable group of people. Our time is spent in risk assessment to prevent self-harm, and MAiD for people with mental illness would further jeopardise safety for these vulnerable people. Suffering is challenging, and what individuals need is palliative care and support to endure it and recover. MAiD for people with mental illness, or for anyone, removes a basic defence against self-harm.³ People with disabilities, mental illness or infirm old age are fragile and vulnerable, and by removing from them the guardrails to death which are a fundamental defence mechanism (which we all depend on) exposes them to the risk of deaths of despair.² People with mental illness or physical disability are not asking for legalisation of assisted dying. It is the well and the educated who want MAiD – for others.⁴ Mental health professionals understand protective factors and ‘why wouldn't you’ factors that keep safe individuals with mental illness. We need to be able to tell them that we will be with them through it all and give them hope, and MAiD will take this powerful support away.⁵