CCBI News: Sedation in Palliative Care at End-of-Life
May 13, 2024 Dear Friends of CCBI, Sedation in Palliative Care at End-of-Life In talking…
CCBI News _ Psychiatric Compliance with MAID; Mental Health Ministry
June 2, 2023
Dear Friends of CCBI,
Psychiatric Compliance with MAiD
In an article dated April 3, 2023, the Canadian Medical Association Journal reported that the average age of those receiving euthanasia procedures (MAID) is 76, mainly people with terminal cancer or heart disease. The article adds that “…the number of recipients with non-terminal conditions is rising.” This is not surprising because, as explained last week and before that, Canadian law does not require an illness be terminal for a person to request euthanasia. I believe many Canadians assumed that was the case at the time of the initial legislation, but it was never the reality.
The article also reports that the number of euthanized people “… has particularly risen in Quebec, accounting for more than 5% of all deaths in the province between 2021 and 2022 – the highest percentage of any jurisdiction globally.” I am not aware of any analysis that shows why this is so, but ongoing research may find some pointers: for example, is palliative care less available in parts of Quebec than elsewhere? Is there more encouragement towards MAID as a choice?
An Angus Reid poll referred to in the article found, “… that although six in ten Canadians support MAID in its current form, only one in three support allowing people to seek MAID purely based on mental illness.” This particular uncertainty remains and will most likely continue, despite the promise of safeguards. It is difficult to see that questions about the reliability of assessing competence and capacity to consent will disappear or be more easily answered in March 2024, when the legislation in this regard is scheduled to be implemented. Questioning whether some people have an underlying desire for suicide or raising doubts about assessing ‘irremediable’ mental suffering are highly charged and not at all easy to answer definitively or objectively.
I was surprised to read that a well-known psychiatrist interviewed for the article stated: “Because the law focuses primarily on patient autonomy, there isn’t much room for clinical judgment (my emphasis added), which has led some MAID providers to approach assessments in a checklist fashion. She added: “We (psychiatrists) say, ‘Let’s figure out if you can have it,’ but we don’t back up and say, ‘Let’s talk about whether you’re making the right decision for you.’” This is a senior physician talking in this vein, and it is eye-opening that the concept of patient authority has such a hold today that professional people are admitting reluctance to use their own clinical judgment. Surely this is a situation where regulatory bodies should intervene where clinical judgment is at issue? If that does not rest with physicians, then assessments in these cases may as well be done by robots using a checklist. “Mrs McQueen, is this the right decision for you? Yes? Tick!”
Further highlighting what appears to be over-reliance on patient autonomy, the same psychiatrist recalls the moral distress she felt in providing MAID to a young man with a highly treatable cancer. Seven other clinicians had been uncomfortable with the man’s request, but because he refused treatment, his condition was technically irremediable and thus eligible for MAID. The doctor reported: “I gave MAID against my clinical judgement because I will always do what’s in the best interest of a patient if they have made a clear and reasoned decision.”
I fail to see how ‘highly treatable,’ ‘technically irremediable’ and ‘against my clinical judgement’ can make sense for any physician dealing with such a case. It seems to me that patient autonomy of this type is in total conflict with physicians’ duties, conscience and responsibilities to the common healthcare good beyond the wishes of the individual concerned. The same doctor says, further, that MAID legislation does not “… require patients to try alternatives to MAID – only to consider them seriously.” Nor does the law require physicians to “…meaningfully discuss a patient’s desire for death or the societal factors that may contribute to their request.”
This does not mean that physicians cannot do so, just that they are not required to do so. Psychiatrists do not have to ask: “Let’s talk about whether you’re making the right decision for you!” If, however, this sort of question is irrelevant and the main point of assessment is to comply with patients’ decisions, then approval of MAID procedures is not only morally bankrupt, but a waste of psychiatrists’ time and a waste of healthcare money. I hope Dr Li, the psychiatrist quoted in the article, is exaggerating somewhat in her comments, otherwise a strong light needs to be shone on these practices by regulatory committees and by families hoping to protect those with mental illnesses requesting euthanasia.
Mental Health Ministry
In a diametrically opposed way of thinking about people with mental illness, an article in America by Bishop John P. Dolan of the Diocese of Phoenix details his founding of a mental health ministry in the diocese. This endeavour stems largely from his personal experience of loss. Bishop Dolan writes: “I am a bishop, but before anything else, I am a human being who understands the severe toll of mental illness, especially when it is left untreated. As a survivor of suicide loss, I have experienced firsthand the pains of mental illness in my own family. Having lost my brother, Tom, my sisters, Mary and Therese, and my brother-in-law, Joe, all through suicide, I understand the importance of finding some comfort in our church and the gift it brings to so many people within our parishes and families.”
He explains how the Church was his true source of solace and comfort, but “… there was a gap between the help they could provide as spiritual leaders and the deeper accompaniment I needed.” This led him to set up the Office of Mental Health Ministry in the Diocese of Phoenix in 2022. The ministry aims to fill the gaps in pastoral care of families dealing with mental illnesses, employing licensed counselors and psychologists who can refer people to professional treatment and guidance. “The office also provides training for our clergy members, religious, deacons, parish ministers, school leaders and laypeople on the most current understanding of mental illness, preparing us as church to accompany those suffering from mental illness with confidence, understanding and pastoral care.”
The program has many volunteer facilitators, some of them deacons, who are trained in the church’s understanding of mental health and who take courses on mental health first aid and literacy. The goal is to have at least one facilitator in each deanery who will “…lead gatherings for those struggling with mental illness, survivors of suicide loss and those grieving the death of a loved one. Facilitators lead group discussions on growing through grief, help people find benchmarks of hope along the journey and ultimately help those suffering see that they are welcome within the family of the church.”
This outreach, clearly modelled on accompaniment, either locally or parish based, is intentionally non-judgmental, welcoming and positive in its approach. It is not only inspirational but more necessary than ever, given the increase in numbers of those with mental illnesses. It provides another avenue for parishes to be more involved in accompaniment at the local level, while working in collaboration with existing, professional pastoral services. This integrated approach stands in marked contrast to increasingly open-access to MAID, which could take hold in Canada if there is little resistance. As Bishop Dolan writes: “The ministry is motivated by the Gospel mandate to love through accompaniment. Certainly, those who struggle with depression, anxiety, post-traumatic stress, scrupulosity and obsessive-compulsive disorder (just to name a few challenges) need continuous love and care from not only the priests, women religious and deacons but also from the wider parish community.”
“Love through accompaniment” or extend MAID? What will we choose?
What’s the status of medical aid in dying in Canada? – CMAJ News
Pope Francis’ Intentions for June: For the Abolition of Torture
We pray that the international community may commit in a concrete way to ensuring the abolition of torture and guarantee support to victims and their families.
Moira and Bambi