*NEW Nov 22*

STAKEHOLDER RESPONSES TO CPA POSITION

CPA leadership’s updated Position on MAiD has been denounced by stakeholders across the country. From our national suicide prevention organization CASP, to indigenous leaders, to experts in Assertive Community Treatment Teams providing clinical care to our most seriously mentally ill, to disability advocates, to legal experts, stakeholders across Canada are raising serious concerns about CPA’s Position on MAiD and calling on CPA leadership to change its Position.

[click links underlined in red below to read stakeholder responses]

The Canadian Association for Suicide Prevention (CASP) calls on the CPA to revise its Updated Position, states that “it is important to be perfectly clear that when considering MAiD in the context of someone who is not dying as a result of their particular condition, we are talking about suicide”, points out that “The CPA is clearly taking a position on the morality of MAiD, despite stating otherwise”, and “In assessing the patient’s eligibility for MAiD, how can your members do so in absence of evidence with respect to the underlying mental disorder being irremediable?”, and states that given “insufficient evidence to support MAiD as a medical treatment, then the requirement [of the CPA Position] to refer a patient forces them to commit professionally unethical behaviour.”

Indigenous leaders across the country express “alarm that, while claiming it is not taking a position, the Canadian Psychiatric Association clearly supports MAiD for mental illness”, are “shocked that [the CPA] November 2021 Position Statement Update still does not address the phenomenon of suicide contagion and the importance of suicide prevention, or the risks of suicide to marginalized populations”, and decry that CPA leadership’s Position “will adversely impact Indigenous populations in Canada as your organizations actual policy documents and Position Statements provide recommendations that continue policies of privilege.”

The Council of Canadians with Disabilities is concerned that the CPA Position Statement “does not address the negative social determinants of health (trauma, poverty, lack of housing, disability-related supports and other social supports) and how they impact on people with disabilities, including mental health disabilities, seeking MAiD”, “does not address suicidality and suicide prevention” and considers this “a serious and dangerous flaw”, “has serious gaps because it has not attended adequately to the influence of ableism on decisions to seek MAiD by people with disabilities”, and is “calling upon the CPA to reform its Position Statement on MAiD”.

Ontario Association for ACT & FACT (OAAF) decries CPA leadership’s Updated Position Statement as representing “a serious and appalling abrogation of moral and clinical leadership” and describe CPA leadership’s support for Bill C-7 as “suicide facilitation”.

Dignity Denied cites “profound concern, indeed alarm even, by the approach articulated on Medical Aid in Dying by the Canadian Psychiatric Association (CPA) in its Position Statement”, and about “a complete omission of intersectionality and in particular how racism and poverty intersect and impact the ‘choices’ one may have and the treatment someone receives and has access to in Canada.”

Legal experts describe CPA leadership’s updated Position Statement as “even more problematic” than the earlier 2020 statement, express concern that the Statement “appears to embrace a position that undermines the professional-ethical-care commitment of the psychiatric community to Canadians” and that “the CPA is endorsing a fundamental abandonment of professional practice standards”, and suggests that “The CPA statement as it currently stands does exactly the opposite of what the CPA suggests in its mission statement.”

In addition to various stakeholder groups, Ontario psychiatrists in a recent MAiD survey conducted by the OMA Section on Psychiatry (the largest psychiatrist group in the country) likewise opposed CPA leadership’s position by a nearly three to one margin (63% to 23%), opposing the position that “patients with a psychiatric illness should have available the same options regarding MAiD as available to all patients, without issues of irremediability in mental illness having been examined”, with an even larger margin of four psychiatrists strongly opposing this for each psychiatrist strongly supporting it.

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  • Dear Colleague,

    You may or may not be aware that the Canadian Psychiatric Association (CPA) released a Position Statement on Medical Assistance in Dying (MAiD) on March 13, 2020. As past CPA presidents, we are writing you regarding serious concerns about this Position Statement and its development.

    Issues related to MAiD and mental illness are complex, and historically CPA members have articulated a range of views. The CPA Position Statement was developed by the Professional Standards and Practice (PSP) Committee without the engagement or awareness of membership, without expert external consultation, and without internal consultation of groups like the CPA Research Committee. The Statement offers no evidence-based guidance on issues related to mental illness and makes no reference to any mental health or mental illness literature or evidence. Given the absence of any guidance, standards or mention of what irremediability means in the context of mental illness, the Statement has been criticized for how it could be ambiguously and even dangerously interpreted in the current politicized debate [see link to September 2020 Canadian Journal of Psychiatry piece on “What does ‘Irremediability’ in mental illness mean?”].

    As recent CPA past presidents, we do not think this is appropriate for our member association. The lack of engagement of membership on this significant and complex issue, which has been evolving over at least 4 years and which members have expressed significant desire to have input in, failed to respect the role of members in a member association. The Statement itself is also highly problematic and potentially harmful. While we appreciate the CPA has since indicated it seeks to engage members in developing a discussion paper, this process should have taken place before development and release of the Position Statement. A Statement cannot be informed by a consultation process that occurs after its release.

    Considering this, and the facts that the government review of MAiD policy initially intended for June 2020 will occur soon, and that the extended deadline for complying with the Truchon ruling is July 2020, we are concerned the current CPA Position Statement will be harmful in influencing imminent policy changes in a way that does not reflect CPA membership input or views. Media interpretations of the Statement have already presented the CPA as supporting MAiD for mental illness without any further evidence-based guidance [see September 2020 Canadian Journal of Psychiatry piece on the “Lack of Scientific Evidence regarding MAiD in psychiatric disorders”]. The last time CPA members were surveyed, in 2016, only approximately 30% supported MAiD for mental illness, and even those expected standards and evidence-based guidelines that the CPA Statement lacks.

    We are asking the CPA to revisit the Statement by temporarily withdrawing it, to allow for a proper engagement process and development of evidence-based recommendations to inform any future Position Statement on MAiD. The CPA has already expressed reluctance to do this, and this process will only occur if CPA members wish it to.

    If you share our concerns, we are asking you to sign one or hopefully both form letters posted online, one to the CPA and the other to the relevant federal ministers. Each letter is very short, and will take less than a minute to read and sign/send. If interested, you may also find additional background material at https://www.webcampaign.org/background.

    We realize most of everyone’s focus is naturally adjusting to our current COVID-19 situation, but given the importance and imminence of potential MAiD policy changes impacting our patients we hope you can take a minute to engage in this process in the next few days, whether or not you are a CPA member, so the voice of Canadian psychiatrists can be heard. We would also ask that you forward this email with attachments to at least 3-5, or more, Canadian psychiatrist colleagues, and psychiatry residents, and that you tweet the website www.webcampaign.org, and use other social media to distribute this campaign, as this initiative will only be successful through ‘word of mouth’ distribution and engagement.

    Thank you again for taking the time to engage in this important and nuanced issue, and to advocate for the patients we entered the profession to help.

    Best regards,

    K. Sonu Gaind, past president, Canadian Psychiatric Association

    Fiona McGregor, past president, Canadian Psychiatric Association

    References:

    Chaimowitz G, Freeland A, Neilson G, et al. (2020). Medical assistance in dying position statement. Canadian Psychiatric Association. March 2020. doi: 10.1177/0706743720919299.

    Gaind, KS. (2020). What does “irremediability” in mental illness mean? Canadian Journal of Psychiatry. Sept 2020 (published online first May 22). pp 1-3. doi: 10.1177/0706743720928656.

    Sinyor M, Schaffer A. (2020). The lack of adequate scientific evidence regarding physician-assisted death for people with psychiatric disorders is a danger to patients. Canadian Journal of Psychiatry. Sept 2020 (published online first May 26). doi: 10.1177/0706743720928658.