Should someone with a mental illness be allowed to access physician-assisted suicide? It’s a complex topic that brings up a lot of medical, legal and moral questions. On February 8, I sat down at my kitchen table to watch a live-stream of a joint event hosted by the Centre for Addiction and Mental Health (CAMH) and University of Toronto’s Faculty of Law. It was on the topic of medical assistance in dying for people with mental illness. It was moderated by Paul Kennedy from CBC Ideas. The panel discussion was fascinating – but it left me and the event attendees with a lot more questions than answers.
In June 2016, the Canadian government passed Bill C-14 to legalize and regulate medical assisted dying in Canada (otherwise known as euthanasia or assisted suicide).
Who is able to benefit from this law? In order to be eligible, an individual must be evaluated by two independent health care professionals to see if they qualify. The person requesting must also be able to give informed consent at the time they receive the medical procedure. They must also be older than 18 years old and meet the following criteria:
1. Have a serious and incurable illness, disease, or disability;
2. Be in an advanced state of irreversible decline in capability;
3. Endure physical and psychological suffering that is intolerable to them; and
4. Their natural death has become reasonably foreseeable.
According to the government, if you are only “suffering from a mental illness” and no other conditions, you are not eligible to receive this service.
In the Netherlands, 1% of all euthanasia is for psychiatric disorders. In Belgium, 15% of cases are for people without terminal disorders. In the Netherlands, 52% of psychiatric cases had attempted suicide and 80% had been admitted to a psychiatric hospital at some point. 56% experience social isolation and loneliness. So we do know that there are areas in the world that allow this. Canada would not be the first in implementing physician-assisted suicide for people with mental illness.
So what are the arguments FOR and AGAINST?
Essentially, assisted suicide is seen as a “permanent and irreversible intervention” so it must be taken very seriously. We need safeguards to protect against errors and protect vulnerable people. We must also keep in mind that there is a remediable nature to most mental illnesses and that the course of the illness is not predictable. It is hard to figure out if there will be a progressive decline in the near future. It is also difficult to determine whether someone will recover or not. There is not a lot of science around this issue so it is hard to make an educated decision.
In the panel, it was brought up that we cannot allow medical assistance in dying with no restrictions. But the question is – where is a reasonable place to draw the line? And are we willing to accept errors that will occur?
The Canadian Psychiatric Association makes the argument that currently, there is no “established standard of care in Canada for defining when typical psychiatric conditions are irremediable.” As such, clinicians would need to make decisions on medical assisted death due to personal beliefs rather than “sound medical science.”
According to a study performed last year, a large majority of Canadians do not support assisted suicide for psychological illness. One of the reasons behind their opposition may also be religious belief.
There is a difference between people who are terminally ill, who don’t want to die, versus psychiatric cases who want to die even if they aren’t currently dying. We must also consider the people with mental illness who have refused other forms of treatment – are those people capable of making decisions about physician-assisted suicide? Suicidal thoughts are also often linked as symptoms of depression. Can we distinguish a desire to die as separate from the illness? The essence of mental illness often leads to symptoms of worthlessness, hopelessness and the belief that a person’s life has little value.
It is also well-known that mental illness can warp our thoughts and weaken our capacity to understand information and the repercussions from our decisions. This article from CBC News points out the valid fact that many people do not have sufficient access to treatment and resources for their mental illness and that is why they are thinking about seeking medical assistance in dying. If people had access to things like proper housing, a support system, sufficient income and employment, then perhaps their suffering could be alleviated. Some mental health advocates argue that we should first work on improving the system before we turn to physician-assisted suicide as an option.
It is worth noting that just because someone is against assisted suicide for mental illness, does not mean that they do not think mental illness is as significant as physical illness. It just means that they understand that treating people equitably means they need to be treated based on their individual needs and circumstances, not treated the same. People themselves with mental illness have been vocal advocates against this potential practice.
I am also trying to empathize with medical professionals and mental health professionals who have been traditionally, up until this point, been working as hard as possible to keep people alive and to prevent suicide at all costs. To make the change to seeing it as a viable form of treatment must be a huge leap.
On the flip side, we need to consider the possibility that “rational suicide” exists – in response to an intolerable situation. It is entirely possible that someone has come to the conclusion that “the life I am able to lead is one that I myself think is not worth living.” For some people, over the course of time, it seems there is no other choice. And to think that recovery is always possible is incorrect.
One of the panelists, Kevin Reel, made some excellent points. He argued that we need to listen to why people are requesting and change our thinking that the assisted suicide is automatically wrong. There shouldn’t be an automatic exclusion due to having a mental illness. We must acknowledge the nature of suffering, and recognize their pain. Kevin also suggested that we reflect on the way we talk about suicide – which is currently seen as horrible tragedies that need to be prevented.
Since many people think that mental illness is just as significant as physical illness (which I agree, of course), then it is believed that to prevent someone with a mental illness from accessing medical assistance in dying would be “discriminatory and a violation of their Charter rights.” People think that is is discriminatory to believe that people who are mentally ill are “by definition, incapable of deciding rationally to kill themselves.” People argue that those who meet the criteria and have tried all other form of treatment, should have the same rights as people with physical illness.
We must consider that just because it is available to people, it doesn’t mean people will take advantage of the opportunity without serious deliberation. Often, they would just like to know the option is available. Do you believe that people should be free, autonomous and have control over their own bodies? If so, than perhaps they should have the choice of when to end their life.
We must also think about quality of life for the person with mental illness. Some people have a form of illness that is treatment-resistant. They can live for years, even decades, with no reprieve from their symptoms and their suffering. And it is definitely well known how debilitating mental illness can be. Physician assisted death could provide a way out with dignity.
As well, it would be interesting to consider the difference of wanting to die by suicide as a reaction to an acute crisis or depressive episode, compared to a desire that is consistent over time.
So what do I think about this topic? I don’t really have an opinion towards one side or the other, to be honest. I still need to do a lot of thinking. I think that for most people, death should really be the last resort in any treatment plan. We should first focus on trying to provide the right resources and helping people build meaningful lives with purpose. That doesn’t mean I don’t think people with mental illness should have equal access – but I think that it will take a lot more debate and research before we let it happen.
What do you think? Should people with mental illness be allowed to access medical assistance in dying? Tell me in the comments below!