Lack of evidence-based medicine in debate around new MAID law should concern Canadians
'In medicine we quantify the harms of new treatments before deciding whether it is acceptable to use them'
This column is an opinion by Dr. Mark Sinyor, a psychiatrist at Sunnybrook Health Sciences Centre and associate professor of psychiatry at the University of Toronto. He has provided testimony about medical assistance in dying (MAID) before both the Senate and the Quebec Superior Court. For more information about CBC's Opinion section, please see the FAQ.
I recently had the privilege of testifying before the Senate of Canada in their deliberations about medical assistance in dying (MAID) legislation. The specific question before them was whether to allow the practice as a treatment for mental illness, which the Senate voted to recommend following an 18-month "sunset clause," and the House of Commons says it would support with a two-year phase-in.
I have no personal objection to MAID in principle. But as a doctor and a psychiatrist who believes in evidence-based medicine, I found both the hearing and the result horrifying.
Bill C-7 would extend MAID to those experiencing intolerable suffering and who are not approaching the natural end of their lives, including those with mental illness.
This is obviously a contentious issue and unfortunately, as in many quagmires in medical ethics, any choice we make as a country will likely result in harm to some people. However, unlike the current political and legal debate over MAID for people with mental disorders, in medicine we quantify the harms of new treatments before deciding whether it is acceptable to use them.
An obvious recent example is the COVID-19 vaccine. It was developed almost a year ago, yet Health Canada and its international equivalents conducted months of testing before approving it while more than two million worldwide died. That was a difficult decision, but the correct one, because it would have been highly unethical to release a vaccine before first conducting clinical trials to establish its safety and effectiveness.
I was there at the Senate to call for the same principles to be applied to the MAID debate.
WATCH | Ottawa prepared to expand MAID to mental illness:
There are many philosophical arguments for and against the use of MAID as a means of remedying suffering. The United Nations Office of the Commissioner of Human Rights, for example, recently put out a statement condemning the practice for those with disabilities on the grounds that it will lead to a devaluing of their lives.
But before having that debate, we have to address a more basic issue.
Those who want this practice to go forward for people with mental illness are making a number of scientifically testable claims. These include the claim that some mental disorders result in patients experiencing enduring, intolerable suffering which cannot be remedied by evidence-based psychiatric treatment; that we can reliably identify such patients; that we can clearly distinguish such wishes from irrational suicidal thoughts; and that legalizing this practice will cause no harm to psychiatric care or suicide prevention in Canada.
Others have called attention to many issues with those claims – among them:
- The recently coined legislative concept of "intolerable suffering" in mental illness has never actually been the subject of scientific study;
- We have no idea how often high quality mental health care alleviates such suffering;
- Even if, in rare circumstances, such suffering can persist after treatment, doctors have no scientific basis to assert that they can predict reliably in whom that occurs.
I could go on. The key point is that one could devise a study to examine each concern according to usual standards of scientific rigour. It's just that some people supporting this legislation don't seem to think that is necessary or worth doing.
The Quebec Psychiatric Association, whose president Dr. Karine Igartua testified at the Senate hearing, released a discussion paper in November that responded to pleas for scientific data from myself and others by saying: "whether to permit MAID … is not an empirical question, it is an ethical one." What nonsensical gibberish. How can we resolve questions of medical ethics without first bothering to collect the precise scientific facts?
To understand the problem, let's imagine two hypothetical scenarios.
In the first, we do careful research and show that five out of every 1,000 patients with psychiatric illness have persistent, unbearable suffering even after high-quality treatment. MAID assessors correctly identify all five and only make a mistake in one in 10,000 patients. The second scenario is the same, except we find that MAID assessors almost never correctly identify those five patients and instead recommend MAID for 50 others whose suffering would actually abate with treatment.
Those empirical differences clearly change the answer to the ethical question.
WATCH | A discussion of reasons against and in support of making amendments to Bill C-7:
Decisions regarding MAID legislation should be based on solid factual evidence. Instead, precisely because some MAID advocates seem to place little value on the usual scientific process, this debate has been an appalling exercise in lazy and specious inferences based on a selective reading of scientific studies that were never designed to answer the questions being posed.
As a scientist, I have to be open to the possibility that all of the claims advanced by MAID advocates are accurate. But enacting law, one which literally governs life or death decisions, based on a possibility isn't good enough.
In other areas of medicine, thoughtful scientists typically devote whole careers to meticulously studying benefits and harms of treatments before rolling them out. Here, that proven approach has inexplicably been replaced with hand-waving and moralizing.
Medical history has shown that when well-meaning people bypass careful science to rush a treatment out before harms are properly understood, it can have disastrous consequences. The opioid epidemic is a tragic, recent example.
The process that the Senate and the House of Commons propose to facilitate the provision of MAID for mental illness really reflects a sunset on the scientific method and usual medical standards. That should worry us all.