A position paper released today by the Canadian Psychiatric Association (CPA) outlines core skills, best clinical practices, and important ethical considerations when evaluating autonomy and consent in requests for medical assistance in dying (MAID) when mental illness is present.
This new guidance, Capacity Assessments and the Assessment of Voluntariness in the Context of MAID Legislation: The Role and Responsibility of Psychiatrists, applies to all MAID requests motivated solely by a mental disorder as well as when a mental and physical disorder co-occur. It affirms the complexity of these assessments but should assure people in Canada that psychiatrists not only have the skills but will be highly cautious, compassionate and clinically rigorous in evaluating capacity to consent to MAID.
“Psychiatrists have the training and competencies to ensure that a patient’s decision-making capacity and voluntariness in their choice to pursue MAID are not substantially impaired by their mental condition, or their social circumstances. Assessing informed consent, including decisional capacity and voluntariness, are core skills of Canadian psychiatrists,” said Dr. Grainne Neilson, lead author on the paper.
People with a mental disorder are currently eligible to apply for MAID only if they also have a physical condition. Federal legislation temporarily excludes requests for MAID on the sole basis of a mental disorder until Mar. 17, 2024.
“The starting point in medical law is that all adults are presumed capable of making their own health decisions. The onus is on the MAID assessor to prove incapacity; it is not on the patient to prove capacity,” says Dr. Neilson.
But decision-making capacity alone is not enough. The paper reiterates that decisions to seek MAID must be voluntary, that is, free from coercion, undue external or internal influence, or “no choice” situations. It can also be considered “informed consent” only after the person has been informed of and offered the means available to relieve their suffering. That includes, as appropriate, counselling services, mental health and disability support services, community services, and palliative care.
The paper underscores that psychiatrists who assess MAID requests or provide consultations must be transparent about any medical uncertainty, particularly as it relates to the limits of current scientific knowledge regarding assessment processes, treatment efficacy and prognosis. It cautions psychiatrists that particular attention should be given when assessing voluntariness for people in marginalized groups whose choices may be additionally constrained by a range of structural and systemic inequities.
“Inadequate housing, extreme poverty or social isolation, long-term imprisonment, or no care available may cause a person to believe that there are no viable, available alternatives to MAID, thereby undermining the voluntariness of the request. Assessors must carefully examine the impact of social and systemic pressures to ensure that these aspects are not the driving force behind a decision to seek MAID,” says Dr. Neilson.
Founded in 1951, the CPA is the national voice of Canada’s psychiatrists and psychiatrists-in-training and is the leading authority on psychiatric matters in Canada.
Contact: Rob Cornforth
Canadian Psychiatric Association
Office: 613-234-2815 ext. 237