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Richard Helppie
Welcome to The Common Bridge. I'm your host, Richard Helppie. Today we're going to be talking about a law in Canada about medical assistance in dying, also called MAID. I invite you to go to the Government of Canada's website for more information. If you go to https://www.justice.gc.ca/eng/cj-jp/ad-am/index.html you can read as much about this law as you wish. Here to talk about it today we have a doctor of psychiatry, Dr. Nick Tito. Nick, welcome to The Common Bridge.
Dr. Nicholas Tito
Awesome. Thank you.
Richard Helppie
Nick, our audience likes to know a little bit about our guests. So tell us what were your some of your early days and your academic preparation and what you are up to today?
Dr. Nicholas Tito
Sure. I grew up in Southern California, it's where I'm actually physically located today, running a clinic down the street. Normal upbringing, I decided I wanted to go to medical school, after a little bit of time with the Army, kind of on a whim, was able to get accepted. I went to a school in Mississippi, and then my wife got a pretty big promotion. I was able to transfer to Touro, which is where I finished at over in New York City, I did a lot of my rotations in New Jersey. I went to med school to be a surgeon and I ended up becoming a psychiatrist. But that's a topic for another whole podcast. But I've loved psychiatry, it's a great field. Especially in the post-COVID era, I think we're getting a lot of attention in the media so it's nice that the other medical specialties are being a little nicer to us lately. They see our importance. So that's a little bit about me, I went to residency then and now in North Carolina and having fun.
Richard Helppie
Great. Well, we did have Dr. Victor Hong on, who is also a psychiatrist at Michigan Medicine, he runs the psychiatric emergency services; Judge Milton Mack talking about the mental health crisis and kind of bringing mental health treatment on a par with medical treatment. What prompted this podcast were some discussions you and I were having online - we don't know each other - about this law in Canada. The law was originally passed in 2016, began implementation in 2017, to set forth guidelines about who's eligible for medically assisted death. And essentially, from my lay reading of it, if you pass certain criteria you can be given a deliberate overdose of drugs and take yourself out or get someone to help take you out. But the change that's going online in just two months, in March of this year, is that you don't need a medical condition, just having a psychiatric condition and wanting to end your life can get you approved. Am I reading that correctly?
Dr. Nicholas Tito
So that is correct. The one caveat is that it seems that in late December - so just a couple days ago - a Canadian court is contemplating putting it on hold. It seems that there is public opinion in Canada to put the psychiatric inclusion on hold. But I'm not quite sure what the status is of that as of now.
Richard Helppie
I went digging for that, went right to the Government of Canada website; I've got a lot of that information in front of me today. They're not advocating it at this point as far as making any kind of a delay but this is about changes to the criminal code. And the Criminal Code, obviously, we cannot have homicide, but they're saying that if you want to get someone to help you - it can be a physician, it can be a nurse practitioner, it can be a pharmacist or pharmacy tech, it can be a family member or someone else to ask or a healthcare provider - it doesn't seem like it limits who might be the support person in carrying out medically assisted death. Am I reading that correct?
Dr. Nicholas Tito
So that is correct and that's in the Swiss tradition. So the Swiss law as it's been since, I believe, 1945...1940s for sure, the way that the Swiss law is written out is as long as you have capacity anybody can help administer these life ending drugs to you so long as they have no benefit from doing so. And so that's why there's a little - it's not that big - there is, you could say, euthanasia tourism that occurs in Switzerland, where it's mostly people from the UK who will travel to Switzerland and utilize commercial businesses that operate this function. Now I don't believe that they take profit from it - they're nonprofits - so I suppose business is the wrong word, but that is kind of the model that the Canadian law is mimicking - the Swiss model.
Richard Helppie
What the Canadian law was, up until this time, that to be eligible there had to be a grievous and irremediable medical condition and, as you said, there had to be a voluntary request and informed consent and that serious illness, disease, or disability - which at the time excluded mental illness - had to be in an advanced state of decline that could not be reversed and that a person was suffering unbearable pain that could not be relieved. Now, under the current law, if your only condition was a mental illness, you're not eligible until March, in just two short months. Why do you think they made this change? I mean, you're someone who is dealing with psychiatric issues all the time.
Dr. Nicholas Tito
I'm glad that the psychiatric issue is coming under the umbrella of medical problems so just the paradigm of seeing it that way, is a good thing. The fact with psychiatry is that it's a field that touches some of the most vulnerable patients in a nation. Oftentimes, a lot of our patients are homeless, unfortunately; they suffer from drug addiction. These are the patients that are usually in contact with adult inpatient psychiatric facilities, state psychiatric facilities, and then prisoners as well, in the forensic psychiatric facilities. So we touch a lot of the patients that there's really no good place to put them, because they have mental conditions that preclude them from really functioning in society in a way that's behaviorally appropriate. Now in that, there's a lot of suffering. I mean, you could take any patient story, patients that, depending on where you fall in the line of moral culpability, any patient story is usually pretty tragic on an inpatient psychiatry unit. A lot of these patients, as they go through their conditions, they have capacity to understand what's wrong with them, they know that life is difficult, and they wish to make the autonomous choice to end their life, because they feel that where they're at, the cards they were dealt, and the options of changing the suffering that's occurring in their life just are not ideal to be able to do that; they don't really see a way out. Good intentioned people have seen the suffering that occurs on our wards, and they've sided with the patient's autonomous request in terms of advocacy. It comes from a good place, it really does. I have not yet seen a single person seeing this as some type of solution to get rid of people that are depressed or having a hard time in life. It's really trying to accommodate an autonomous request from a person who is suffering. And suffering of the mind has been something that has gone through various stages through the ages, from madness, all the way till now we call it mental illness. This is where psychiatry and philosophy begins to intersect; how do we as a society interpret that? And then as physicians, how do we advocate for our patients best? Some physicians have decided that full autonomy, and even the autonomy to end one's life, is best for advocating. I personally disagree with that and so that's, I think, why you've brought me on the podcast. But I do want to say that reasoned people, I think, can come on both sides of the issue.
Richard Helppie
And our podcast, The Common Bridge, is designed more to inform than to influence. I just found it interesting because Canada makes a lot of noise about indigenous peoples and who occupied the land before Canada yet, when this law was first introduced, a lot of the very vocal opposition came from the indigenous peoples because they've said, look, we're at the bottom of the levels of society. We do suffer from alcoholism, addiction, poverty, hopelessness, and you're going to make us eligible for further eradication. And they started drawing the obvious parallels that you'd expect. I mean, it was not just Nazi Germany. It's the predisposition in Iceland to abort, euthanize babies in utero that have Down's Syndrome. Now, it's not a requirement, but it's certainly encouraged. So I kind of tried to work this out, talking with Dr. Hong [where you have] a person coming in and [they are told] oh, you have a problem because you're suicidal and yet this is almost being presented as, well your solution is suicide. How does a layperson like me sort that out?
Dr. Nicholas Tito
That's an issue that we're still trying to get a better idea about. The way that some of my peers in psychiatry are framing suicidality is changing. I have my own personal views on that but I see the reason through it, there is a logos to it, so to speak, I personally fall in the realm of suicidality is a psychopathology and so because it's a psychopathology, how can we grant capacity to a patient wishing suicide? Now, where this gets murky, in terms of logic, is patients that have less than six months to live, so typically hospice patients, even the most so hard-lined, no to euthanasia physicians, when they encounter someone suffering immensely from cancer or any innumerable number of deadly conditions who wish to end their life early, their hearts are usually softened to that request, because death is unfortunately a very ugly thing and it can be very, very painful and difficult for some people to pass.
Richard Helppie
That's what the Canadian law does differentiate; there are people whose natural death is considered reasonably foreseeable. Physicians have been doing this since the beginning of time, easing people along with pain medications and, at times, enough pain medication to bring about the end of their life and I think that's seen as compassion. But then there are people who don't have a natural death in the foreseeable future and I would imagine that would take in a lot of Alzheimer patients; they're healthy physically yet they're just not there mentally. It seems to be opening a door to the medically assisted death for Alzheimer patients and those with other cognitive deficits.
Dr. Nicholas Tito
Yes. I believe that my peers who are for this would say - I'm going to speak for them hesitantly - that once we open the floodgates for physicians, to begin to tease out how do we go about legalized euthanasia we'll be able to start developing guidelines of who does qualify. What are the nuances of Alzheimer patients, what are the nuances of patients that have cancer but it's not lethal in the next six months, those types of things. I caution against that, for the sake of there's a lot of gray area in this, and medicine in particular is not an exact field; a lot of what we do operates in the gray, especially in psychiatry. So I do worry about patients falling victim to a system that has a good intention, but unfortunately, has a very final outcome. It's the finality of the euthanasia that alarms me the most.
Richard Helppie
Indeed, and I think everybody reaches a point where they can accept their mortality, and perhaps understand that this is going to be the end of their life on this earth. I'll leave the spiritual discussion for a later day. It's the fear that the first step on medically assisted death - sanctioned by the state, supported by the state - leads to almost a cultural norm that it's the right thing to do or worse yet, as we've seen in some of the most horrible societies, it's demanded; Cuba, again, Nazi Germany, other other totalitarian states. Isn't that a legitimate fear?
Dr. Nicholas Tito
I believe so. I absolutely believe so. I'll use an example of a patient that sparked my interest in this when I was in medical school. I've been reading up on this for quite a while now and the literature on this is actually quite prolific. But we had a patient who came through and she was a nice older lady. She had had a fight with her family, because she had felt that...she had been somewhat depressed for the past year since COVID started - this was 2020 - she had been slightly depressed, and because she couldn't really see anybody anymore she wished to end her life. There was nothing wrong with her medically so like I said, I want to include psychiatric under medical, but for the sake of the conversation, somatically she had hypertriglyceridemia, which can be serious, but hers was a mild case, and she was on Lipitor, and that was really it. So she was really in great health, but she had purchased the means to travel to Switzerland, get a hotel - the flight was booked, the hotel was booked - and the contract had been written up for her to terminate her life in Switzerland. She sprung this on her family out of the blue, so the family called the authorities. The psychiatrist at the local ER has the power, in this case, to pretty much have the authorities haul her in - hopefully not in handcuffs, usually that's not the case. So she did agree to come to the psychiatric ER and there, she was convinced that she should go into a three to five day stay on an inpatient adult psychiatric unit. While she was on that unit, she firmly believed that she should continue with euthanasia and that it was none of our business what she does with her life. Now, I believe she has some great points there, I really do. I completely sympathize with her. Unfortunately, this patient was involuntarily committed after that, the nuances of why we can get into if you want, but she was involuntarily committed. Then during that stage she agreed to change her mind on wanting to commit euthanasia and she was released. She was put into the care of her ex-husband, she moved back to another state. I caught up with her about eight months after that on a phone call, and she was very happy to still be alive. So that's where I got this idea that I'm really against this because the patient, she was autonomous, she did have capacity while she was with us, but she was having a psychopathology; whether it was the depression, whether there were other things that we weren't picking up, whatever was causing it, it was a psychopathology. So to acquiesce to an autonomous request [that is] so final in [the] absence of a life ending illness, I'm obviously glad we didn't do it, because she's still alive and happy to be so.
Richard Helppie
I really appreciate you sharing that story with us, because I think it really highlights the dilemma. And under this current Canadian law, it would have been fine for lethal drugs to be supplied, if not administered to this woman, and with no opportunity for her to be healed. I think we can all see the difference between somebody that is suffering from a mental illness - and that's now coming into parity, we think, in society with medical illnesses, we don't know exactly who's going to be treated - yet on the medical side, there's a lot of evidence now where physicians can look and say this person that has pancreatic cancer, for example, that it's gone beyond the point where we can do anything more, let's make the person's passing as easy as possible. To me, those are two very, very different things. And then of course, we go back to what you're saying about the homeless and the addicted and perhaps the disabled, because I know in some of my reading in preparation for this episode today, there are Canadians that say, does that mean we're going to take those that can't get care or perhaps haven't been successful in life, and they're just going to be eliminating themselves before their time. I remember reading as a youth in 1968, a writer named Kurt Vonnegut wrote a lot of short, crisp novels, one called "Welcome to the Monkey House" and one of the elements of that was something called "ethical suicide parlors" that were set next to every Howard Johnson - that was Vonnegut's wit being put into this very serious issue. 1973, the famous movie, "Soylent Green" with Charlton Heston and it was Edward G. Robinson's final role, and in that Edward G. Robinson is an elderly man without hope who went to the suicide parlor and eased himself along. So we've seen these kinds of ideas be put forth in the arts. Are we coming to a point in history where we can save a lot of lives and extend life; we all know people that whatever happened to them today had it happened ten years ago they wouldn't be with us, is this some kind of counterbalance? A way to move the death rate to a more historical norm?
Dr. Nicholas Tito
I would hesitate to go that far. But it certainly could be used in that manner. If someone malicious enough were to see the nuance of what this would allow, I think you could devise programs that could lead to that, absolutely. Because, I mean, we deal with suicidal patients on an inpatient psychiatric unit almost every day. I believe that if you gave these patients the ability, okay, here you go, I'm going to pretty much load the gun for you and hand it to you and it's not going to be bloody, it's going to be nice and you're going to fall asleep and that's it, I think a lot would take it. But only in that moment because we all hit lows - all of us. I've definitely hit a low in my life where maybe I would have taken it because it seemed so bad. I think the leading neuroscience is showing us why that happens; why do we get such a low place and then three weeks later you'd never known that we were there. The neuroscience, that's pretty complex and it gets into belief formation and how that occurs in the mind, which we really don't have that great of an understanding of, but we're starting to. What's resurging in neuroscience circles is belief formation, especially in light of all the new buzzwords of misinformation, disinformation. I'm really interested in how do people believe what they believe. Why do they believe what they believe? And once you have a belief, why is it so hard to change it? Even when presented...like, all of us, we believe something until we're presented with just clear, overwhelming evidence, it's really hard to break that belief. So a suicidal patient, they really believe that life is worthless, and there's really no point to being here; whether that's true or not, it's really a discussion for the philosophers, that's not really the discussion of a psychiatrist. I think this; the psychiatrist should always have the view of yes, life is worth living.
Richard Helppie
I know it's been said that suicide is a permanent solution to a temporary problem. People never know what their capacity to work through things might be. That's where, again, something as difficult to diagnose as a mental illness because there is no lab test, there's no MRI, there's no definitive way to say this person suffers from anxiety or schizophrenia or any other diagnosis, and then the exit plan being euthanasia. That's a difficult hurdle. One of the things that that always concerns me is something that people have termed bureaucratic momentum. Basically bureaucratic momentum in the United States is when we put 535 people in houses of government and tell them they can make laws and pass laws and guess what they do; they make laws whether we need them or not. So when I think about things like MAID, the law in Canada, are there going to be enterprises set up that say, look, we're here to administer the chemicals to end your life and eventually someone in the government is going to say, hey, do we really need to invest in those? And well, you know bureaucrats [will say] oh, yes, we do because we had X number of cases last year, therefore, that proves we need to do that. Therefore, the manager the next year says, hey, look, if we're going to keep our funding going, we've got to find this many cases, and it sets a very ill intentioned cycle into motion.
Dr. Nicholas Tito
Right, and that was never the purpose of the program to begin with. I completely agree with that. That is, I would say almost inevitable but definitely a risk with this program, absolutely. Very few physicians are doing this in Canada to my knowledge, but the way that it works is most physicians are very uncomfortable with it, whether they agree with it or not. There are just a few physicians that have - and I don't want to even attribute maliciousness to them at all - they've had patients, maybe hospice patients or patients where it really made sense in their minds to do this, and so they've become kind of the go-to physician for euthanasia in that area. A hospice patient - that's a philosophical issue for the society to decide really, I think that's completely reasonable either side you're on. But my fear is that a new burgeoning medical specialty would come out of it, not so much palliative care, but euthanasia care. I just don't think that's what we're in the business of.
Richard Helppie
I think that most people would agree with that. Again, if we saw a person with a devastating cancer or another illness - ALS - and said, I've had enough, make me comfortable, and if you give me a little extra for that, it'd be great. I think people can get comfortable with that. But it's enterprises set it up for the specific duty of euthanizing people; then it gets down to the natural next question as well, who's eligible, where do we find them, how do we get them here, how do we refer them? And to your point about most physicians wouldn't be interested in doing this, it only takes a couple. I mean, we had, 30 years ago, a guy named Jack Kevorkian. I know the way it was reported in the papers about what a good thing he was doing but I had first-hand knowledge of what the police that were coming upon his death scenes were showing and they said it was really like a horror movie. Then other physicians that told me that during his training, his fascination with death was in some odd deaths during that time; they told me this off the record. So it doesn't take that many to really make a difference. Intriguing what you said about beliefs. I think you're really onto something there because we've been unmoored in a certain respect about what is believable. Just recently, I read a poll that 38% of Americans - this is a Gallup poll so this is a credible sample and so forth - 38% of people said they had no trust at all in newspapers, television or the radio - none, zero. And only 7% said that they completely trusted those sources. So to me, that's another element, that we've become unmoored from what's the truth. I've seen people hang on to beliefs that just have been debunked and proven false - and it's across the political spectrum - they just hang on because they were told that at one time, they bought in, they're not letting go. I mean, great case in point, we have people that have views on vaccines, use of masks, lockdowns; you can't move somebody out of one camp and into the other. Very rare.
Dr. Nicholas Tito
I know with the anti-vax folks - and I even hesitate to say that - but I think what happened there, a lot of people, just because of the nature of vaccines being something that goes into your body, and then a law that made a lot of people uncomfortable - whether valid or not - so anybody that had a kind of pre-existing skepticism to a vaccine and then you're forced into it, I think that triggers our ancestral well, that's a predator and our brains are wired that it's a predator. And to prove it's a predator, I have to touch it, feel it, taste it. It's not just some guy in the news is going to tell me, my grandmother needs to tell me that. The way that our brains are wired is for survival. I think the rapid change in the past just five decades, in terms of our living standards, is really testing our ability to create truthful belief. I absolutely agree that it's difficult to choose what to believe. I know, like, I'll take my own life, as much as I would want to believe what's absolutely true - when you're determining what's true - you've really got to fight what your mom and dad told you, at least for myself, whatever view it is; or I've got to fight what my really trusted friend told me. So I think when people are coming into interaction with the medical system and the medical system is saying, no, trust us, we went to medical school for this, we have most of the right answers; when you do make a mistake it just really solidifies that bias of no, I can't trust you. I think there's utility to that but then there's also a downside.
Richard Helppie
Indeed, I think well spoken. This has been a great conversation. As we move to our close, is there anything we didn't talk about that we should have, or any closing comments you'd like to leave with the audience of The Common Bridge?
Dr. Nicholas Tito
Sure. I just want to highlight in my readings on euthanasia. St. Augustine really wrote a lot about this and he was a Catholic priest who did a lot of philosophy writing and doctrinal writing for the Catholic faith. He wrote about the law of double effect. What the law of double effect is, is that I'm not morally culpable for doing something good now that will lead to something potentially bad later. And it's the word ìpotentiallyî that's the actionable word there. So what St. Augustine argues is that palliative care, which is giving patients morphine, until they pass away but in the name of pain alleviation, is morally acceptable under the Catholic's faith laws. Judaeo-Christian thought is really the paradigm that America is in and so it's a good way to look at this. But if you go to euthanasia, where okay, even though the good end is the alleviation of suffering that "potential" is now changed because you know that you're killing somebody. So it's not so much that the patient is morally culpable for killing themselves; the physician is morally culpable for causing death because they knew it would cause death. Whereas when you're giving morphine it's not as straightforward as okay this is definitely going to kill you. It's more, I'm going to relieve this pain and it's possible that it can [kill you]. But when you administer some of the euthanasia drugs, that is the intent - to kill - and I find that fascinating because it's a very nuanced subject. I've said what I believe on it, but I can completely understand the other side who say, but you kind of know you're going to kill the person when you give them morphine. I love that debate. I think it's an interesting topic and I would just encourage everybody to read some of St. Augustine's work on that. It's quite fascinating.
Richard Helppie
I think it's a great way to end our talk. And I can envision myself as that patient in a lot of pain and saying, no, you do what you have to do, I know I'm not getting out of this bed. And if it's a little extra today versus next week, or the next month, you've got a green light from me.
Dr. Nicholas Tito
Just one hundred years ago, a lot of people would slit the throat of their own cow for meat. Our society has sanitized - and largely for good - so many things that were a common day and so most people have no interaction with death until really, it's kind of knocking on their door now. I think we're just starting to see the fruits of that kind of reality of modern life. So it's fascinating.
Richard Helppie
It is and we're putting it in the hands of government, giving them the power over life and death. And the responsiveness of our government, or lack thereof, is a subject that we cover often so finding these policy answers is very important and that's why we have these discussions. (Dr. Nicholas Tito: Very good.) So we've been with Dr. Nicholas Tito today, psychiatrist, talking about the law in Canada for medically assisted death and all kinds of philosophy around that. So for our listeners, our readers, our viewers, I hope you stayed with us all the way to the end here and didn't react just to the title. Along with our guest, Dr. Tito, this is your host, Rich Helppie, signing off on The Common Bridge.
(Listen, Watch, or Read) Medical Assistance in Dying- Canada's Controversial Law.