Medical assistance in dying—is there a case for including persons with mental illness?

By Nicholas Delva, Anees Bahji

Over the last couple of decades, medical assistance in dying (MAiD) has become legal in a few developed countries. Developments in this area have been primarily driven by patients, with general support from the population. Governments have been cautious in the development of legislation, which is not surprising given that such activity used to be both illegal and against prevailing religious and moral beliefs. Patients with a mental disorder as the sole underlying condition (MD-SUMC) have generally been excluded as potential candidates for MAiD. Even where it has been legal, MAiD MD-SUMC has not always been accepted; for example, in Belgium, doctors were charged for providing a lethal injection to a 38-year-old female patient with autism and depression; the doctors involved were, however, eventually acquitted in 2020.

The most recent revision of the MAiD legislation in Canada, proclaimed in March 2021, excludes MAiD MD-SUMC, but the matter must be studied to make further changes. Our paper clarifies the issues of importance in determining whether MAiD MD-SUMC should be available. We believe that competent patients with MD-SUMC should qualify for consideration for MAiD.

Some doctors in Canada have developed considerable experience and expertise in MAiD. Dr. Konia Trouten recently described her work in this area as “a way to honour people with the grace and agency they deserve.” Regarding MAiD MD SUMC, opposing views have been taken in the lay press: Colby Cosh has argued persuasively that MAiD MD-SUMC should be legal. On the other hand, Fr. Raymond de Souza sees the mentally ill in grave danger from MAiD. Thus, there is a healthy national debate on the details of to whom and how MAiD should be available in Canada.

Both authors have been interested in MAiD for several years. AB became interested primarily out of a lack of understanding about MAiD, which prompted him to learn more about the subject. When he learned about the implications for people with mental disorders, he was fascinated by the disconnect — why are psychiatric patients treated differently? Is it stigma? It seemed like a polarizing and controversial topic, and there were many unanswered questions and many strong opinions. He sensed that a lot of the adverse reaction was fear-based, with psychiatrists concerned about what allowing MAiD for psychiatric disorders might do to their role and the quality of their relationships. A significant development for ND was attendance at a clinical presentation of a young adult female patient who had been allowed to take her own life by starving herself to death. On first hearing about the patient, his immediate reaction had been that more could and should have been done, but after hearing the details, it was clear that this had been the right clinical decision. The alternative of repeated involuntary hospitalization and forced feeding was not right or humane in this case. Having accepted that some patients with MD-SUMC should be allowed to die, and having looked after patients who died by suicide, ND was interested in understanding more about who might appropriately qualify for MAiD MD-SUMC appeared to be the humane approach for some persons. The advent of frank discussions between psychiatrists and their patients about MAiD MD-SUMC would represent a significant development in Canadian psychiatry. In addition to the relief of interminable suffering in some patients, the availability of MAiD MD-SUMC might prompt discussion of other options for treatment and thus forestall some suicides.  However, the main clinical imperatives will always be a humane concern for the patient’s well-being and respect for their autonomy.

Paper title: Making a case for the inclusion of refractory and severe mental illness as a sole criterion for Canadians requesting medical assistance in dying (MAiD): a review

Authors: Anees Bahji, Nicholas Delva

Affiliations: Department of Psychiatry, Queen’s University (ND); Department of Psychiatry, University of Calgary (AB)

Competing interests: None declared.

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