Bill C-39, which was tabled on February 3 in Ottawa, defers by another year the eligibility for medical assistance in dying (MAID) for people whose only mental health disorder (MSD) is medical criterion invoked. Although across our province, the College of Physicians and the Association of Psychiatric Physicians of Quebec (AMPQ) consider themselves ready, and the Association of Intervention Groups for the Defense of Mental Health Rights in Quebec (AGIDD-SMQ) is disconcerted by this postponement, which it sees as yet another proof of the paternalism and epistemic injustices suffered by people living with an MSD, the federal Minister of Justice considered that we had not reached the social consensus needed to move forward.
It seems appropriate to seize this time off to make progress in this essential conversation. But for that, it is necessary to remove the few myths that fuel the outcry against the idea that people living with an MSD can also assert their rights by requesting medical assistance in dying.
We often read — and this is a first myth — that the community of people suffering from mental health disorders, the first concerned, is unanimously opposed to it and that the dominant discourse, mobilized by “experts”, despises their voice. But this affirmation in the same breath invisibilizes the voice of the many groups for the defense of the rights of people living with an MSD (I have already quoted the AGIDD-SMQ) who claim this right, in addition to discrediting the testimony of the few people who ask this care for themselves.
Of course, there are also organizations (like Not Dead Yet and Compassion Choices), citizens, and researchers who ardently oppose MAID (in general). But is the community unanimous on this issue? No. An article by political science professor Susan Behuniak published in 2016 documents these disagreements very well.
Over the past year, we have also had the opportunity to read in several columns—and this is a second myth to dispel—that all people living with a mental health disorder will be eligible for MAID and risk losing their lives if, plunged into a period of despair, they ask for it. Such an assertion arouses dread and consternation (rightly if it were true!), but it neglects that all people who are diagnosed with a mental health disorder (1 in 3 people during their lifetime in Canada…) do not obviously do not meet all the eligibility criteria.
Take the criterion of consent. Specialists know that emotional distress, phases of major depression or even periods of psychotic crises, for example, temporarily compromise the ability to consent to this care, in addition to clouding the decision-making capacity. However, the process of the person applying for MAID, in addition to being evaluated by two doctors and a psychiatrist, over a period extended to 90 days, must be “maturely thought out” (AMPQ, 2020) and register in the long time of reflection.
Any decision taken impromptu, or in the hollow of the depressive wave, would not appear to have been carefully considered, any more than the desire for death would be considered rational by the relatives and the care team. People who would find themselves in such a situation would simply not obtain MAID. The benevolent paternalism that underlies safeguards would somehow protect them from themselves.
And that’s without taking into account the requirement to meet the eligibility criteria of “serious and incurable disease” and “advanced stage of decline in capacity that is irreversible”, which specialists recognize as being difficult to establish when it’s about mental disorders. Favoring prudence and precaution (and not the cavalier attitude that certain opinions suggest), the Association of Psychiatric Physicians of Quebec recommends to its members to “abstain in case of doubt” (AMPQ, Document reflection, 2020).
Some argue, however, that it is impossible to draw the line between cases where the disease is treatable and cases where it is refractory to treatment. But can we agree with the specialists that the line of demarcation is often difficult to draw, without claiming that it is in any case impossible? That the evaluation is a tightrope exercise which falls under the art of clinical practice, and that a part of uncertainty always hovers (as is sometimes the case with diseases of the body) does not in itself justify the application of an a priori ban on MA for all people suffering from an MSD.
A French researcher opposed to MAID for MSD wrote that Canadian law should go further, and that before judging the irreversibility of the disease, it should require the person living with MSD to have subjected to a wide variety of psychological and pharmacological treatments, with different professionals, going so far as to require that she undergo nothing less than electro-convulsive therapy (electroshock). In other words, as long as everything, down to the most intrusive and controversial therapies, has not been attempted, we should oppose a categorical refusal to the request for MA.
The groups for the defense of the rights of people living with an MSD have historically denounced the massively suffered treatment and forced internment, the sometimes unbearable side effects of certain treatments, and the relentless treatment. The principle of personal integrity enshrined in the Constitution gives them the right to refuse treatment. Why not leave it up to the people most affected to decide how many and what treatments they will find acceptable for themselves? How far are we going to push what the philosopher A. Baril calls “the injunction to life”?
In the context of our societies marked by “structural sanism” (discrimination against people with TSM), the testimony and words of these people are commonly discredited as “false”, “exaggerated”, “irrational”. », and their suffering and desire for death, invalidated. They suffer from what is called, in philosophical jargon, “epistemic injustices”.
In reality, in such a context of structural sanism, the risk is much greater that able-bodied people, who live with a mental health disorder, find themselves unfairly deemed incapable of deciding for themselves their own care, whether they are believed to be rational and supported in their approach. Because that is what it is more fundamentally about here: being able to hear the voices of suffering people with all respect and taking them seriously. Validating their existential suffering would also represent, according to many, the first step towards the appeasement of their desire to die.