A shortened version of this piece appeared in The Toronto Star, November 26, 2022.
Autonomy in the face of scarce resources is a false promise
At the moment I most needed acute mental health care, I was lobbing rocks into a bucket in anticipation of drowning myself in a remote, pristine lake. But the line I tied to the pail and to my ankle did not hold and I just bobbed on the surface like a beach ball.
This sorry incident took place some two months after I’d spent six weeks in hospital suffering from severe depression. Although I initially felt optimistic about my discharge, recovery was elusive and certainly not fast enough for my liking. I felt desperate.
I consider myself one of the lucky ones. I eventually found help – a psychologist at the hospital who had known me when I was well agreed to see me again as an out-patient. Together, we worked through some of the issues plaguing me. I regained the will to live. Not everyone is so fortunate.
The lack of available mental health services, the high expense for non-insured psychotherapy and the lack of access in many parts of the country are but a few of the barriers people face in trying to secure competent mental health care.
And now there is another complication to throw into the wash: the possibility of MAID (medical assistance in dying) based solely on mental illness.
At first, I was eager to see the right to die as something people with mental disorders should be able to access on an equal footing with those who suffer from physical illnesses.
I still tend to toward that position, but I want to see safeguards built into the system, standards that protect the most vulnerable. The promise of autonomy in the face of scarce resources is a false promise.
If one can’t access psychotherapy or afford the medications that might help ease one’s suffering, exercising the right to a dignified death is precipitous.
There is a danger that vulnerable people, those without means, may resort to MAID because they can’t afford the necessities of life. Experts indicate that such cases have occurred in Canada.
I know what it can be like in the depths of a depression. One doesn’t believe the gloom will ever lift. It can seem that the world and one’s loved ones would be better off without one’s presence. Neither of these statements is true, but perception is skewed by overwhelming clinical depression. Suffice to say it’s not a great time to make big, life-altering decisions.
What safeguards are needed? Some people just don’t respond to the treatments available. What if they’ve tried everything medicine has on offer? Does that put one in the position of having the right to choose to end it all?
It’s not a decision I would want to rush. I am concerned that by March 17, 2023 the law of the land will permit MAID based solely on mental illness, without a full set of standards to govern cases or specialized training for medical practitioners.
We need to extend the safeguards now in place. Two specialists to assess the individual instead of one, wherein the second physician would rigorously investigate treatment options, would constitute such a cautionary measure. So would lengthening the 90-day waiting period between when one applies and can receive MAID, when death is not foreseeable.
Interestingly, in the Netherlands 90 percent of psychiatric euthanasia cases are not accepted, although raw numbers have increased over the years.
A Quebec government committee studying the issue recommended disallowing MAID based solely on mental illness. Certainly, that is the most cautious route. It bothers me in that scenario, however, that a truly desperate individual who had exhausted all treatment options would not have the right to end their life in a dignified fashion.
I agree with those advocates who maintain that what the patient wants should be supreme, but with the caveat that this right is accessed only once the full slate of care options has been tried.
Finally, MAID must not become a ready alternative for vulnerable people who cannot make ends meet. Many people with serious mental illness are poor, can’t work, have fallen through the cracks. It would be ironic if the one policy that might ‘catch’ them is one that would allow them to kill themselves.
When I stood over that serene lake years ago actively choosing suicide, MAID was not an option. I wouldn’t have been a good candidate for it either. Only two months out of hospital, I was still on my first drug trial. It didn’t turn out to be successful. It took another few months,another drug and intensive counselling, before I fully re-entered the land of the living.
In view of that kind of situation, I would want policy makers to be parsimonious in the granting of MAID – there were still too many unexplored routes to wellness. Recovery takes time.
When recovery is not possible, assuring the judicious application of MAID means improving the accessibility and depth of mental health services in this country. And it means extending the safeguards that exist, before widely granting the right to MAID based solely on mental illness.
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Miriam Edelson is a Toronto writer. Her latest book, The Swirl in My Burl: Essays, is out now.