Psychiatry’s cognitive dissonance problem

While many celebrate Ottawa’s decision to delay legislation on expanding medical assistance in death (MAiD) to include those whose sole condition is suffering from mental illness, questions remain as to how fair this is to the patients the changes are supposed to help.

Psychiatry has done little to warrant praise for its role in this societal fiasco and many practitioners maintain broken ideologies on the central question.

We on the “pro-MAiD for mental disorders” side of this weighty societal argument use accepted medical ethics norms in coming to our foundational claims. We argue that having a mental disorder should not preclude one from the benefit of a MAiD assessment given its availability for those with physical illnesses intolerable in nature. This argument is rooted in a basic belief that mental suffering rivals and can exceed physical suffering.

We view a blanket ban based on mental disorder to be unconstitutional and out of touch with Canada’s high court ruling in the Carter decision. More than this, such a ban would represent the worst of mental-health stigma because it approaches the question from a starting point that says psychiatric patients cannot make treatment decisions. This is an estranged and bizarre departure from medical ethical norms and any reasonable appreciation for patient autonomy. It turns treatment capacity norms upside-down by assuming patients are incapable of making a medical decision even before any assessment of their capacity to make the decision.

Given these monumental encroachments on classically held ethical views in medicine, a rational question emerges: What is going on?

One hypothesis relates to a widespread cognitive dissonance on the part of psychiatrists. A tension exists within mental-health clinicians when it comes to what is in the best interests of the suffering patients we treat. We frequently encounter patients who want to bring an end to their life, and we work tirelessly to move them away from this position. Often, we are successful; sometimes we are not. Failures mark the darkest and lowest parts of a career in psychiatry. It should come as no surprise, therefore, that the push back against MAiD for the mentally ill is usually founded in a sense that MAiD would be incongruent with our larger aims – to prevent death by suicide and to comfort the suffering.

What this automatic view blows past is any nuanced, mature and emotionally impartial understanding of those larger aims. In addition to preventing death by suicide in the traditional case, we are also obligated to help our patients avoid suffering and to support them when our efforts produce incomplete and unsatisfactory outcomes. And here lies a greater tension now inflamed by a progressive court ruling and a zealous federal government – who precisely is best positioned to qualify and quantify suffering?

According to the courts, and the legislation as it exists, it’s the patient who is best positioned to adjudicate when suffering has become “intolerable.” Much of the tension therefore emerges as a conflict between patient and doctor. The age-old debate around paternalism in medicine – and just how much is too much.

In cases of terminal physical illness like cancer, those who qualify for MAiD are given the reins in large part and can choose how exhaustive their treatments need to be prior to deciding upon MAiD. Few would argue that the approach to MAiD should be identical in cases of physical suffering and mental suffering. Our safeguards will and should adjust to the nature of the illness but a blanket prohibition against the mentally ill is not a safeguard, it’s a scam.

One complicating factor relates to the nature of mental disorders. They are not “terminal” in the traditional sense, and this is where many get hung up. The exception that gets overlooked is traditional suicide. Even here, death cannot be called terminal in the technical sense, in that it is not predictable with the certainty of a brain cancer, for example. That the road to MAiD for mental disorders is complicated should come as no surprise. In line with this, it is our view that complexity is no excuse for inaction.

It is our view that complexity is no excuse for inaction.

Happily, in Canada, the political and judicial elite seem keen to forward this service to those suffering with longstanding, incurable and intolerable mental disorders. It would be easy to blame the delayed rollout on haphazard and fanatic politicians, but the specialty of psychiatry in this country has much to answer for. The pathway to MAiD for the mentally ill has been easily foreseeable since the original Carter ruling in 2015. In the years since, psychiatry has been largely asleep at the wheel and ultimately in denial. This approach served absolutely no one well, including the patients at the centre of the issue.

In the fall of 2021, I attended the Canadian Psychiatric Association’s annual meeting in Toronto. Of all the seminars and presentations during the weekend conference, only one touched on the topic of MAiD. Curiously, the presentation focused on MAiD in borderline personality disorder. Why was this curious? Borderline personality disorder likely represents one of the trickiest mental disorders in relation to the MAiD question. Emotional regulation issues, unstable relationships and self-harm are all mainstays of the disorder but so too is impulsivity – clearly a complicating factor for any clinical assessment for MAiD.

More maddening than discussion being limited to a personality disorder that often remits in intensity and has sound treatment strategies was the nature of the discussion that followed. As the talk concluded, one seasoned physician commented that he’d been in practice since the 1960s and had yet to meet a patient who should have been considered for MAiD.

Moving quickly past the fallacy of authority he projected to the crowd, you’ll be unsurprised to find out that it was championed by other physicians in attendance. It all amounted to perfectly crystallized groupthink and a cowardly refusal to object to tortured logic on the part of many of those in attendance. Abandoning core principles is fine, but your reasoning must outweigh the counterargument and be evidence based – neither of which seem true in this case.

At the end of the day, psychiatrists must be honest with the facts. The facts are that psychiatry and all the strategies we use to instill hope, to perfect treatments, to meet patients where they are and to shelter them from suffering is very much an unfinished work in progress.

With this in mind, we on the side of patient choice have carefully considered the question, weighed the pros and cons and feel comfortable stating publicly that having a mental illness should not preclude one from decision-making related to suffering and end-of-life care. We have decided that there is little merit in continuing to pretend that mental and physical suffering differ in ways that matter.

Our side is simply arguing that in some cases, the suffering and mentally ill should have equitable access to an assessment. The specifics of that process need to be carefully crafted. We can and should disagree and debate. We can and should erect strict safeguards based on the best science and evidence we are privy to. But we need to be honest and admit that a process can and should exist. Pressing the brakes may always seem like a good idea as we could always stand to benefit from more time. But it is our patients who stand to benefit from equitable, fair and, yes, timely laws and medical norms. With the election clock in Canada ticking, and with a Conservative majority in the cards, this issue demands priority.

The paternalistic view that no mentally ill patient should have access to a MAiD assessment is as broken as the paternalistic view that we can stop all suicides in community. We cannot and, in fact, choose not to do this and the reasons why relate to our core and fundamental valuing of patient autonomy, bodily integrity and civil rights. We strive to live up to these values while balancing them with common sense measures, safeguards and compassion. As one esteemed mentor impressed upon me during training, a good clinician knows when and how to “let a patient live their life.” I would extend his teaching to include when and how to let a patient die.

And to an important patient we now turn to for the final word.

In a taped address to Parliament in November 1992, Sue Rodriguez famously asked, “If I cannot give consent to my own death, whose body is this? Who owns my life?”

Psychiatrists so sure of their position on this issue should reflect carefully on this memorable and important line of thought.