Suicide solution

A year of tennis in Medical Assistance in Dying and suicide

It’s been quite a rollercoaster year for debate around Medical Assistance in Dying and suicidality. Here’s a timeline and some commentary on the back-and-forth of whether suicide and MAiD are the same and if suicidal people should be allowed MAiD.

April 2022: MAiD is not suicide.

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Dr. Stephanie Green on letterhead from the Canadian Association of MAiD Assessors and Providers (CAMAP), of which she is president, briefs the parliamentary Special Joint Committee that MAiD is not suicide. CAMAP presently has $3.3 million in federal funding to develop a national MAiD training curriculum.

November 2022: MAiD is suicide and should be used to help people kill themselves.

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Justice Minister and Attorney General Hon. David Lametti calls MAiD a “species of suicide” and seems to rationalise MAiD as lending a hand to suicidal people who somehow struggle to kill themselves on their own. No suicide prevention from this minister.

February 2023: Suicidal people can’t have MAiD.
Federal Mental Health and Addictions Minister Hon. Carolyn Bennett declares in the House of Commons and on Twitter that, “people with suicidal ideation are NOT eligible for MAID and are instead offered supports.” Suicide prevention from this minister though. Hard to reconcile her words with the Justice Minister’s comments.

March 2023: MAiD is not suicide.

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AMAD committee member and psychiatrist Senator and Dr. Stanley Kutcher Tweets that MAiD isn’t suicide, echoing Dr. Green’s reasoning.

April 2023: MAiD can be suicide and is OK sometimes.

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MAiD practitioners and advocates try to square the circle in authoring Health Canada’s optional Model Practice Standard, Background Document, and Advice to the Profession. These documents advise that suicidal people can access MAiD if the request aligns with their values and is made during a “period of stability” not “crisis.” It advises against approving or providing MAiD if a person has “acute” suicidality. Note that the Model Practice Standard is “neither authoritative nor binding” nor an official Clinical Practice Guideline. Optional, in other words.

“neither authoritative nor binding. Rather, they serve as templates that physician and nurse regulators can use to modify or establish their own authoritative and binding regulatory standards.”
- Background Document: The Work of the Medical Assistance in Dying (MAID) Practice Standards Task Group

Thus the official workaround, whither and whether MAiD and suicide, boils down to a suggestion by the federal government that suicidal people be eligible for MAiD if they are stable and not acute. Interesting here is the similarity to earlier language used by Dr. Green in explaining how she discerns the quality of mental illness and therefore eligibility in her MAiD assessments, depending whether she deems them “active” or “stable.”

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I’m not a medical specialist, but when I ran searches for “stable suicidality” through Google Scholar, I found peer-reviewed literature that defines clinically stable “as a change in the dose of antidepressant medications that is less than 50% during the past three months based on a comparison between the highest and lowest antidepressant doses” when assessed by psychiatrists.

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Interestingly, this research, which looks at patients with depression over Covid-19, found that suicidality is still “common” among clinically stable patients with major depressive disorders. Note too that it is psychiatrists with expertise in suicidality and mental illness who determine clinical stability with a clear definition, not the family or other non-psychiatric doctors or nurse practitioners who often assess and provide MAiD by making individual ‘judgement calls.’

So here we are, SEVEN years since MAiD became legal in Canada, and lawmakers, clinical practitioners, advisors and advocates are unable to find a consistent position on MAiD and suicide. This also comes two years after MAiD became legal for people with physical disabilities who may also have a mental illness, who are not dying. And one year before it becomes legal for people only with a mental illness, of which suicide is a major indicator. Physical and mental illness, as experts have known since long before MAiD became legal, are drivers of suicide.

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Remember, the Criminal Code states that MAiD assessors and providers only need to have a “reasonable but mistaken belief” that a person qualifies for death.

So much for suicide prevention and accountability.

Incidentally, suicide bereavement is associated with diagnosable prolonged grief disorder and other mental illnesses as well as with further suicidality among sufferers.

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In theory, such a diagnosis from grieving the loss of a loved one to MAiD could also qualify the bereaved for MAiD, especially when MAiD for mental illness alone is legalised in March 2024.

What could go wrong?

1. “Suicide is almost always a traumatic event, often violent, frequently impulsive, usually carried out alone or in secrecy, and it leaves devastation in its wake- for families, for first responders, often entire communities. By contrast, medical assistance in dying involves a legal framework, a rigorous process, the involvement of multiple health care practitioners and the option to involve many loved ones.” - Dr. Stephanie Green to AMAD

2. “…remember that suicide generally is available to people. This is a group within the population who, for physical reasons and possibly mental reasons, can’t make that choice themselves to do it themselves…this provides a more humane way for them to make a decision...”
- Hon. David Lametti in the Toronto Star

3. “MAID & suicide are different. Suicide is often impulsive. MAID MD-SUMC requires a minimum of 90 days waiting & is not impulsive.” - Sen. Stanley Kutcher on Twitter

4. “Assessors and providers must take steps to ensure that the person's request for MAID is consistent with the person's values and beliefs, and is unambiguous, and enduring…it is rationally considered during a period of stability, and not during a period of crisis.”- Health Canada Model Practice Standard for MAiD, 2023.

5. “I asked Stefanie Green how she decides whether a patient with a mental health condition has the competence to choose euthanasia, she said that she makes a judgment call about whether a patient has an “active” or “stable” case of mental illness. For “active” cases, she will consult a specialist; for “stable” cases, she proceeds on her own.” - Alexander Raikin’s interview with Dr. Stephanie Green in The New Atlantis

6. Zhang Ling, Cai H, Bai W, et al. (2022) Prevalence of suicidality in clinically stable patients with major depressive disorder during the COVID-19 pandemic. Journal of Affective Disorders 307: 142–148. DOI: 10.1016/j.jad.2022.03.042.

7. Note that Kutcher is an author of this 2012 source, but his current position (footnote 3) seems to contradict his claims here:
“Patients who have recently been diagnosed with a life-threatening or progressive chronic illness or an illness that would bring severe humiliation and shame to them in their sociocultural context may be at increased risk for suicide, particularly if the reaction to the diagnosis is severe and the patient lacks social supports. Physical illness associated with functional impairment, cognitive impairment, pain, disfigurement, increased dependence on others, and decreases in vision or hearing are associated with increased risk of suicide. Neurological disorders such as epilepsy, multiple sclerosis, Huntington disease, and brain and spinal-cord injury are associated with a particularly high risk for suicide.” - Chehil S and Kutcher SP (2012) Suicide Risk Management: A Manual for Health Professionals. 1. publ., 2. ed. Oxford: Wiley-Blackwell. https://www.wiley.com/en-gb/Suicide+Risk+Management:+A+Manual+for+Health+Professionals,+2nd+Edition-p-9780470978566

8. Tal Young I, Iglewicz A, Glorioso D, et al. (2012) Suicide bereavement and complicated grief. Dialogues in Clinical Neuroscience 14(2): 177–186. DOI: 10.31887/DCNS.2012.14.2/iyoung.