Medical Assistance in Dying when The Sole Underlying Medical Condition is Mental Illness
Journal of Psychiatry Reform vol. 10 #8, special edition July-August 2023
Alan Eppel MB, FRCPC
The idea of euthanasia, medical assistance in dying (MAiD) or assisted suicide had been considered taboo in medicine for millennia. The oath of Hippocrates, the principles of medical ethics and religious teachings have all warned against hastening a patient’s death. The concept of “first do no harm” has been a foundational tenet of ethical medicine.
This has changed profoundly in several countries over recent decades and specifically in Canada starting in June 2016 with the legalization of MAiD.
Medical assistance in dying is legally defined in Canada as:
- i) the administration by a physician or nurse practitioner of a substance to a person at their request that causes death;
- ii) the prescribing or provision by a physician or nurse practitioner of a substance to a person at their request, so that they may self-administer the substance and, in doing so, cause their own death .
We are shaped by what we do. To shift from a focus on healing and beneficence to one privileging autonomy and the legal right to choose assistance in dying is a radical change in the culture of medicine.
Extending Eligibility in Canada
Eligibility for MAiD will be extended to those whose sole underlying medical condition is that of mental illness or mental disorder. With the passage of Bills C7 and C39 in 2023, persons suffering solely from a mental illness will be eligible for MAID as of March 17, 2024 .
This extension is consistent with the recognition that:
- i) suffering from mental illness can be as unbearable and intractable as that in physical
- ii) individuals with mental illness for the most part retain decision-making capacity and can exercise their autonomy.
Where the problem arises is the ability to predict the future course of mental illness and to determine if the illness is irremediable. The legislation does not include a requirement that all accepted treatments be attempted at maximal intensity and for adequate duration.
I would contend that a clear diagnosis of mental illness must be a prerequisite. DSM-5-TR and ICD-11 classification systems, although problematic, must be a starting point.
There is no question that suffering with mental illness can be just as severe as in the most extreme medical illnesses. Examples include extreme and treatment-resistant melancholic depression that has not responded to maximum doses of medications from different classes of antidepressants over extended periods, and where electroconvulsive therapy has been ineffective. Intensive psychotherapy should also be a requisite intervention.
Again I would advocate that all possible treatment options should be attempted . Prediction of potential treatment response in the future is difficult. How long should treatment be continued before concluding that the condition is irremediable?
This dilemma was identified to me by a 43-year-old married mother of one who has experienced prolonged recurrent major depression with suicidal attempts. Looking back at the time when she was depressed, she stated
“I would have wanted MAiD but I recovered and lead a rich life”.
Another area that remains problematic is what should be done when a patient refuses a specific treatment modality, for example, electroconvulsive therapy which remains the most effective treatment for severe melancholic depression. The legal position has been taken that patients have the right to refuse any specific treatment and this right should be preserved, however, I would contend that eligibility for MAiD could not be justified in these cases.
Individuals requesting MAID may be feeling despondent, hopeless and suicidal in response to homelessness, poverty, social deprivation, racism and other societal and economic factors. These should never be accepted as criteria for MAiD in the absence of irremediable psychiatric suffering. It is the responsibility of provincial and local social service systems to provide housing and income supports.
I propose that patients requesting MAiD should be assessed over a period of several months to ensure consistency of symptom levels and wishes to die.
Assessment should include family members and discussions with the family physician and psychiatric treating team. Psychiatric consultations should be sought in all cases.
- Medical Assistance in Dying. Ministry of Health Ontario.
- Legislative Summary of Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying)
- Jones E. The Life and Work of Sigmund Freud Vol 3; Basic Books. New York; 1957, p.246
- Bill C7. An Act to amend the Criminal Code (medical assistance in dying)Second Session, Forty-third Parliament, Statutes Of Canada 2021
Commentary by Marianne Dees PhD :Suffering and Autonomy
Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands General practitioner, MAiD provider and assessor, senior researcher Radboud Medical Centre, member Royal Dutch Medical Society. Physician Trainer for Support and Consultation on Euthanasia in The Netherlands’ (SCEN).
In the context of a request for MAiD I hold the opinion that it is extremely important to be precise in wording. Patients do not suffer from a mental or a physical illness. The illness as such is the underlying cause for their unbearable and intractable suffering. They experience their suffering as unbearable as result of their actual, expected or feared symptoms and/or loss of functioning and what this means to them.
Just as in patients with a physical illness, the unbearable suffering of patients with a psychiatric illness is a personal experience influenced by the symptoms of the illness, personality characteristics (which can be a challenge in cases of personality disorders), life history (narrative ) and ability to cope with the situation. In patients in which a psychiatric illness underlies their unbearable suffering, their narrative without doubt is influenced by their life story. This is colored by their psychiatric history, which is shaped by the caregivers and therapists who accidentally did or did not pass by.
Regarding decision-making capacity I would prefer to talk about decision-making capacity regarding the request for MAiD rather than the concept of being able to exercise their autonomy. Autonomy is a complex idea especially in the context of MAiD where relational autonomy is at stake. The assessment of MAiD decision-making capacity ( Appelbaum & Grisso) better respects patients with a psychiatric illness as autonomous agents with the right to decide what happens to their own life. It also helps to protect patients with diminished capacity for autonomous decision making.
The thirty years of my own experience as MAiD assessor and provider in the Netherlands taught me that for psychiatrists it may be difficult to start with the patient’s perspective on her or his suffering and to explore the physical, psycho-emotional, social and existential symptoms and what they mean to the patient. Psychiatrists in the Netherlands tend to override autonomy when it comes to treatment options. I have often observed that psychiatrists find it difficult to accept that a capable patient has the right to make a “stupid” decision (in the eyes of the physician) regarding treatment options. Shared decision-making in relation to requests for MAiD is not always self-evident. I have often had the impression that shared decision-making with patients with a psychiatric diagnosis is more difficult for physicians then when it concerns patients with a physical diagnosis. If this is the case in Canada as well, I would advocate placing more emphasis on autonomy in patients for whom psychiatric illness is the sole underlying medical condition for their unbearable and intractable suffering.
Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med. 1988 Dec 22;319(25):1635-8. Erratum in: N Engl J Med 1989 Mar 16;320(11):748.
Barton W. Palmer, Alexandrea L. Harmell. Assessment of Healthcare Decision-making Capacity. Arch Clin Neuropsychol. 2016 Sep; 31(6): 530–540.
Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Weel C van. Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. Psycho Oncol 2010; 4:339-352.
Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Vissers KC, Weel C van. ‘Unbearable suffering’: a qualitative study on the perspectives of patients who request assistance in dying. J Med Ethics 2011; 37:727-73.
Commentary by Mona Gupta MD, FRCPC: How Much Suffering Is Enough?
Mona Gupta MD CM, FRCPC, PhD is the chair of the Government of Canada Expert Panel on MAID and Mental Illness. Dr. Gupta is a psychiatrist at the Centre Hospitalier de l’Université de Montréal and Associate Clinical Professor in the Département de Psychiatrie et d’Addictologie at the Université de Montréal. She is an active researcher in ethics and philosophy of psychiatry and serves as a Senior Editor of the journal Philosophy, Psychiatry and Psychology. She was Chair of the MAID advisory committee for the Association des Médecins Psychiatres du Québec and co-author of its December 2020 discussion paper on assisted dying and mental disorders. She was also a member of the Council of Canadian Academies Expert Panel on MAID: Working Group on MAID where a Mental Disorder is the sole underlying medical condition whose report was tabled in the Parliament of Canada in December 2018.
In our everyday work as psychiatrists, we undertake certain tasks that are structured by legislation, the processes leading to involuntary hospitalization being one of the most common. When we set out to do those tasks, we do not reach for these statues to tell us how to practice or what decisions to take. Laws provide a framework within which we practice, but the actual details of what to do and how to do it come from the community of practitioners: training by expert colleagues, recommendations of professional societies, clinical practice guidelines, and regulatory guidance. Our society has chosen to situate assisted dying as act provided by healthcare professionals, and so the same logic applies. Alan Eppel’s suggestions for how we can establish whether a mental disorder can be considered a grievous and irremediable medical condition in the context of a MAID request reflect exactly the kind of thinking the clinical community must engage in to guide practitioners in this area of assisted dying. That said, our thinking should be guided by certain considerations three of which I discuss below.
Eppel writes that, ‘To shift from a focus on healing and beneficence to one privileging autonomy and the legal right to choose assistance in dying is a radical change in the culture of medicine. I am not sure why he positions respect for autonomy and healing as contrasting positions. In all areas of medicine, we try to facilitate healing in a way that respects patients’ beliefs, values, and vision of good health. That this now extends to assisting people to die is new, but the idea that the goals of care are shaped by an individual’s wishes is not foreign to contemporary medical practice. If assisted dying is a clinical practice, then the guidelines we set for ourselves about how to work in this area should reflect this continuity with the rest of practice. Of course, any practitioner who does not believe that continuity is ethically possible or permissible, is not required to be involved in assisted dying.
Eppel’s paper goes on to wrestle with the challenge of prognostication. While Eppel – and many others – discuss this problem as it applies to mental disorders, the inability to accurately predict the long-term trajectory of disease applies to many chronic conditions, not just mental disorders. This issue arises now for some ‘Track 2’ cases (when the person’s natural death is NOT reasonably foreseeable). Psychiatrists can look to how our colleagues in other specialties establish the incurability of disease and irreversibility of decline as it concerns other chronic, non-degenerative conditions.
Finally, in discussing the possibility of MAID for persons with mental disorders, Eppel writes, ‘The legislation does not include a requirement that all accepted treatments be attempted at maximal intensity and for adequate duration.’ The legislation says nothing about treatment for anyone, not only persons with mental disorders. As is already the case for people with other conditions, it is up to the clinical community to establish these thresholds. Indeed, this is the heart of the matter: for chronic conditions like mental disorders, how much intervention is enough for a person’s condition to be considered incurable and their decline irreversible? For some, the answer to this question is that no amount is ever enough. Essentially, these practitioners do not believe it is possible to establish that a mental disorder is a grievous and irremediable medical condition. But for those who think there can be a limit to what a person must undergo before permitted to access an assisted death, how much is enough is the fundamental ethical question we must try to answer together as clinicians. The Criminal Code of Canada cannot reason clinically on our behalf.