​​MAiD mental-health debate should be about ‘agency’, not ‘autonomy’

I have been working as a psychiatrist for almost 50 years, dealing every day with the struggles of ordinary people with the challenges to living – from youths trapped by the pandemic and the media to women stuck in toxic work environments or abusive relationships and refugees trying to get a foothold in our society. Every week, I would hear the urgent wish to die rather than live with one’s predicament.

I also have worked in several hospitals and encountered suicidal patents (before or after suicidal attempts).

Over the years, my patients have taught me what would make them want to die, and more importantly, what has made them want to live.

The current debate about MAiD, I believe, is based on the strange relationship between Psychiatry and Medicine. Historically, doctors working with mentally ill people (before they were called psychiatrists – the Royal College of Psychiatrists in England was only established in the early 1970s and I am one of the early members). The discovery of penicillin (by accident) led to the age of pharmaceuticals; the discovery of chlorpromazine and imipramine (also by accident) allowed the “psychiatrists” to join the ranks of other doctors with claims to some effective tools, This led to the age of powerful “pharma” that further supports research in biological psychiatry and eventually to the 1990s’ Decade of the Brain. Psychiatry has truly become a sub-specialty of medicine.

However, working with my patients has taught me that their experience of “illness” is quite different from those with physical ailments (not discounting the many patients who suffer from both). The recent discussion of “social determinants” of health within both psychiatric and general medicine would indicate the limitation of a purely biological perspective both in causation and treatment. The pandemic has also highlighted the impact of social disconnectedness as an epidemic that is no less serious.

“Mental health” is indeed too important to be left to psychiatrists alone (as stated by a previous president of the Royal College of Psychiatrists). Yet, they are the only ones who can prescribe medications and have a commanding influence on the mental-health policies of most governments.

Last week, I saw (virtually) John, who has been very depressed for years. He lives in public housing, sharing his tiny space with bed bugs (even after several cleanings because they just crawl back in from the corridor). He is also under constant threat of eviction because of his hoarding (holding onto the only things that give him meaning in life). He has insomnia, aggravated by the sounds of noisy neighbours through the thin walls. He is totally isolated; my call is the only one for him in the whole month of February. He does not go out; he subsists on whatever food he can afford.

I can only provide some ineffective pills called antidepressants, but he says that my call is important to him.

What he needs would be many things, including better housing and a supportive visitor (his case management service has a time limit). I can only provide some ineffective pills called antidepressants, but he says that my call is important to him. I wonder if he will be asking for MAiD when it is to be implemented? I guess I would refer him for an expensive consultation and then, if approved, a medical procedure to end his life (all paid by our government).

Luckily for me, I also saw Sophia in the same week. She attempted suicide several times in the past few years but has stuck with me since I support her initially amorphous idea about her possible recovery. Slim as it was in the beginning, it has slowly become stronger through participation in self-help groups and volunteering in an agency that understands and accepts her. It was fortunate that such agencies exist despite the limited fundings government offers to support such important work.

Then I read about the 23-year-old woman with PTSD (from the airport bombing in Belgium) who went through assisted suicide last year. She was tried on a multitude of medications (like so many of our patients). She refused to work with a trauma therapist, bent on obtaining the assisted suicide, and got what she wanted.

All that distinguishes these “ordinary” people is the will to recover. This is something we work hard on. That may be why so few of our suicidal patients actually kill themselves years later. If the option of an “easy” death is available, I believe quite a number of them would choose that over the hard work to recover.

For the government (and the people who elect them), MAiD is an easy solution, at least fiscally speaking. A group of psychiatrists will become experts in assessing this new treatment they can administer (death). A government institution will be developed to manage the increasing demand. The investment will be covered by the reduction in provincial support program payments to these people. I guess the need for community services will also be reduced.

I do believe that the option of MAiD may be good for a very small number of patients. However, I believe the issue is not about “autonomy” but “agency.” Our society should provide adequate resources for all “ordinary” people to have the agency to live their lives instead of the current situation that, for many, makes it easier to die than to live.

In the future, our grandchildren will look back on us and determine if we have done the right thing for them, and for humanity.