Be with me
This article first appeared in the Minden Times in February 2024.
I don’t want to want to die alone, she said. That’s why Elfrieda, the beautiful and talented concert pianist with the devoted husband, wants her sister Yolanda to take her to Switzerland to have a medically assisted death. She wants to die and has tried several times, for no good reason other than that living is unbearably painful.
Marion Toews’ book, All My Puny Sorrows, was published in 2014, two years before Canada legislated Medical Assistance in Dying (MAID). Four years after Toews’ sister ended her life. And many more years after her father kneeled in front of a train. And her niece took a dive into a rushing river. She knows the pain of living with suicide – before, during, after. Her main characters are women, and she paints them brilliantly: they’re smart, sassy, resilient, challenged, imperfect in the extreme. They have children with different fathers, take cruises when their daughters are in the psych ward, have desperate indiscriminate sex, expect their adolescent children to fill adult gaps. They’re eminently loveable. And relatable, if we’re feeling brave.
Yoli is the unsuccessful sister, but she is the only one whom Elf can trust to make the Switzerland arrangements, even though she’s the one who doesn’t easily have the means. Toews is a gifted writer which sustains the book’s excruciating honesty. (There’s also a movie, same name, equally well done, available for rental on Apple+ TV. If you like your whisky straight, try the movie; if you prefer a bit of mix or ice, the book’s your bet.)
The federal government just kicked the can of expanding MAID legislation three years down the road (conveniently after the next election). They want assurance that adequate mental health resources – a provincial jurisdiction -- are available. Everyone who must create or vote on that legislation, or implement it, should be required to read Teows so they understand in their gut the current – and maybe forever - shortcomings of the mental health system.
Elf’s experience is that it requires the person who wants to die to change their mind before they will be helped, surely a different approach than in most areas of medicine. Why? Perhaps because the medical system has no idea why some people are unbearably unhappy or otherwise mentally malfunctioning, and because they don’t understand it, they don’t know how to fix it. Yoli’s take on Elf’s time in hospital is that the medical staff bullies the patients into saying and doing ‘normal’ things (eating, socializing, taking pills) so that if they improve, the medical profession can take credit. If they don’t, well, medicine tried its best. If they’re fooled, well, that’s one less patient to worry about.
So it's probably a good idea to work a little harder before the legislation is expanded to allow mental illness as a sole reason for MAID. The rate of medically-assisted deaths has grown faster in Canada than in any other country that permits assisted death. In 2022 MAID accounted for 4% of Canadian deaths; it took the Netherlands 14 years to get to that percentage. Some worry that the rapid growth is attributable to the lack of support to live a dignified life, which makes a dignified death a reasonable option.
This will be a problem on steroids if the door is opened to those with mental illness. One in five people in Canada say they have mental health challenges. Not all are equally debilitating, diagnosis is (apologies, psychiatry) a crap shoot, treatment is frequently unsatisfactory, recovery is often mysterious. How can we know when we are providing the scope and quality of services to people with mental illness that would allow us to ethically offer medical assistance in dying? Yoli turned herself inside out with that question; it won’t be much easier even with the objectivity of professionalism.
But objective professionalism is also difficult to achieve. It’s so tempting to blame the patient – or, for the many who never make it to treatment, the person -- for the ‘choice’ they make when the official pick list is so sparse and unimaginative. Nor is it likely to improve any time soon. Mental health gets 7% of the health budget. It is under-researched, under-resourced, with little agreement about effective intervention or how to define ‘cured’. It gets lumped in with ‘bad’ behaviours that stigmatize it. We have been socialized to see maladaptive behaviour as moral lapse.
It’s the nature of choices available to people with mental illness that is the pivot point in the debate. One in five is a scary proposition: that’s a big probability you could be or know an Elf or a Yoli.
