What would J.R.R. Tolkien say about MAID for mental illness?

Journal of Psychiatry Reform vol. 11 #1, January 2024

Author Information

Aaron Prosser, MD MSc

Psychiatry Resident

Department of Psychiatry and Behavioural Neurosciences

McMaster University

Funding statement: This work is not supported by any sources of funding.

Conflicts of interest: The author has no conflicts of interest to declare.

Acknowledgement: I would like to thank Dr. Scott Y.H. Kim and the reviewers for their helpful feedback on this essay.

Abstract

Canada is due to decide whether to legalize medical assistance in dying (MAID) for mental illness in March 2024. This essay describes the beliefs that justify MAID for mental illness, how they are a departure from ancient wisdom about suffering, and how they are a worrisome sign of inequality and unfairness in access to mental health treatment in Canada.

Medical assistance in dying (MAID) for mental illness is when a doctor or nurse practitioner prescribes medications with the intent of ending the life of a non-terminally ill patient who wants to die, but whose sole underlying condition is a mental illness. At the time of writing this essay, Canada is due to decide whether to legalize this on March 17, 2024. We should all reflect on why Canada is legalizing an action recently considered a crime. What beliefs justify MAID for mental illness? We can find answers in J.R.R. Tolkien’s book, The Lord of the Rings.  In despair, the protagonist Frodo tells Gandalf (the wise wizard) that the creature Gollum deserves to die for his treachery. Gandalf replies:

“Deserves it! I daresay he does. Many that live deserve death. And some that die deserve life. Can you give it to them? Then do not be too eager to deal out death in judgement. For even the very wise cannot see all ends.”

Gandalf’s words were prophetic because, in the end, Gollum plays a pivotal role in overcoming the great Enemy of the story, Sauron.

These words also express ancient and cross-cultural wisdom about suffering: there is an objective purpose to suffering because the arc of the universe, while long, bends towards goodness. What may seem evil in our eyes may, in fact, be good, given enough time or seen from a wider perspective. But “even the very wise cannot see all ends”, and so we must be humble before passing judgment about what is good vs. bad, whether a life is or is not worth living, including our own. This ancient idea is the basis for hope in the face of suffering, which – by its nature – often can seem senseless and unbearable. For if there is an objective purpose to our suffering, then hope is not merely wishful thinking, it is a rational belief based on the order of things.

The justification for MAID for mental illness rejects this ancient wisdom. At the heart of MAID for mental illness is the belief that meaning and purpose are entirely subjective. The individual defines their own concepts of existence, of meaning, and of purpose, especially about their own suffering. An individual’s will is not just the highest authority, it’s the only authority on the meaning/purpose of their suffering.

If a person consistently insists that their life is not worth living because of their suffering, on what grounds can we question that? If a person concludes that there are no more acceptable treatments for their suffering, again, who are we to question that? We’ve already conceded that the individual is the highest and only authority on the meaning/purpose of their suffering and worthiness of their continued existence.

Some may claim that it is personal opinion and bias if a healthcare provider invites a person to reconsider MAID for mental illness by saying that suffering has an objective purpose. It may be hard, even impossible, to know the purpose of our unique struggles, given our limitations. However, we do not need certainty to live, we just need hope, a trust in the rational order of things. What this “rational order” may be is beyond our focus here, which is merely to state that many wise people from the past understood suffering to have an objective purpose. A common theme of ancient thought is that the great and small struggles of life are tools for actualizing our potential. People are like raw gold in a forge. The fire, the heat, and the burning away are necessary to actualize the potential of the raw material, creating pure gold.

Do we really believe these ideas – once seen as perennial wisdom – are now merely personal opinion and bias? If we do, then J.R.R. Tolkien would probably say MAID for mental illness is holding up a mirror, reflecting what we no longer believe in.

We also seem to be letting go of our commitment to equality and fairness. People who seek and receive MAID for mental illness in other countries tend to be women, socially isolated and lonely, and have complex mental disorders, including histories of trauma, suicidal behaviours, personality disorder, and comorbid conditions (multiple mental disorders, medical comorbidities, e.g., chronic pain, musculoskeletal disorders, cardiovascular disease) [1, 2]. Publicly funded treatments in Canada are insufficient for these complex patients, especially the psychotherapies, which are short-term cognitive-behavioural therapies usually in a group setting. Medications, hospitalization, and brain stimulation often play an adjunctive role in the recovery of these complex patients relative to psychotherapy.

For many of these complex patients, long-term individual psychotherapy (weekly appointments for 1 year or more) is superior to the types of psychotherapy the public funds [3]. Reducing the social factors driving loneliness/isolation and healthy relationships are also essential. Sadly, only the socially connected and the financially privileged (or those with generous private insurance benefits) can access these types of treatments in Canada.

Psychiatrists and family physicians are publicly funded and could provide long-term individual psychotherapy to complex patients but there are challenges. Presently, there are not enough psychiatrists and MD psychotherapists to meet the mental health needs of Canadians in a timely manner. Financial factors may also be a challenge. Billing codes and publicly funded outpatient psychiatric services (e.g., hospital clinics, collaborative care models) tend to encourage psychiatrists to be consultants who do short-term or periodic follow-up, primarily as psychopharmacologists.

The implication of these considerations is that unequal and unfair access to mental health treatment in Canada may result in more women and vulnerable people disproportionately dying by MAID. These will be unnecessary deaths because how can we say someone is “irremediable” if we have not provided adequate treatment? Moreover, the medical field does not have accurate methods for predicting if a person with mental illness is irremediable (“For even the very wise cannot see all ends”) [4]. Indeed, the majority of people who seek MAID for mental illness change their mind [5]. The government of Canada and its advisors have not proposed any safeguards that even attempt to address the obvious problems of (1) no public funding for long-term individual psychotherapy for complex patients (i.e., people who are chronically suicidal with histories of trauma, personality disorder, and multiple psychiatric/medical comorbidities), (2) inaccurate predictions of irremediability, and (3) false positives. J.R.R. Tolkien may have a final word to say in response to this inequality and unfairness: “do not be too eager to deal out death”.

References

1. Nicolini, M.E., et al., Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders. Psychological medicine, 2020. 50(4): p. 575-582.
2. Kim, S.Y., R.G. De Vries, and J.R. Peteet, Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA psychiatry, 2016. 73(4): p. 362-368.
3. Leichsenring, F. and S. Rabung, Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis. The British Journal of Psychiatry, 2011. 199(1): p. 15-22.
4. Nicolini, M.E., et al., Irremediability in psychiatric euthanasia: Examining the objective standard. Psychological Medicine, 2023. 53(12): p. 5729-5747.
5. Thienpont, L., et al., Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ open, 2015. 5(7): p. e007454.