Who but those who have experienced it can appreciate the soul crushing anguish of mental illness? Afflictions of the mind can be paralyzing and fundamentally change the way we perceive ourselves (I am worthless), anticipate the future (my prospects are hopeless), and experience the world (life is unfair and unforgiving). The combination of self-loathing, hopelessness and despair can tragically lead to suicide.
Parliament’s Special Joint Committee on Physician-Assisted Death, nevertheless, urged the federal government not to exclude individuals with psychiatric conditions from being considered eligible. Their reasoning comes down to this: mental suffering is no less profound than physical suffering, so denying individuals with mental illness access to physician hastened death would be discriminatory and a violation of their Charter rights.
People with mental illness are no strangers to discrimination. Two-thirds suffer in silence for fear of rejection and mistreatment. Only one in five children who need mental health services receive them, either because of concerns they will be stigmatized or supports are simply not available. Doors are constantly being closed on the mentally ill, denying them of stable employment, social opportunities, secure food and housing; and sometimes fundamental protections under our criminal justice system. They are marginalized, victimized and vilified.
Mental illness is one of the best predictors, more so than poverty, of inequitable access to healthcare in Canada. People with severe mental illness die about 25 years earlier than adults in the general population.
Making a fairness argument for the availability of physician-hastened death for a group of people treated so unfairly seems a cruel irony. In Oregon, having a psychiatric condition does not preclude eligibility for physician-assisted suicide. However, that condition must not impair the patient’s capacity to give consent and must, as in every other eligible case, occur alongside a medical condition with a prognosis of less than six months. Experts I met involved in Oregon’s Death With Dignity Act, in place 17 years now, could not fathom the idea of providing assisted suicide purely on the basis of non-terminal psychiatric disorders.
In the Netherlands, Belgium and Luxembourg, psychological suffering stemming from either a physical or mental condition is considered a valid legal basis for physician-hastened death. They account for a small but growing minority of death-hastening cases. Last month, a critically important study was published in the journal JAMA Psychiatry by American psychiatrist, Scott Kim.
Kim and his team reviewed 66 case summaries, published online by the Dutch regional euthanasia review committee between 2011-14, of people who had received either euthanasia or assisted suicide for psychiatric reasons. The majority were women, with issues including depression, psychosis, post-traumatic stress disorder, anxiety and substance abuse; some also had various forms of cognitive impairment (e.g. intellectual disability, early dementia) and autism. Most had personality disorders and were described as socially isolated and lonely. In one quarter of instances, despite differences of opinion between physicians, death hastening proceeded. In about one third of cases initially refused, most were carried out by new physicians willing to comply.
The parliamentary committee position seems premised on the recognition that physical suffering and mental suffering can be equally devastating. That does not mean, however, they can be approached the same. The nature of mental illness often leads people to see themselves as worthless, to believe that their situation is hopeless; and to perceive — often reflected through society’s judgemental gaze — that their lives have little value. But this context should help us see that a death hastening response is fraught with hazard; and runs counter to a recovery oriented practice advocated by the Mental Health Commission of Canada.
Like all Canadians, people with mental illness have rights that are protected under the constitution. And like all Canadians, these rights need to be balanced against the interests of a free and just society, wherein vulnerable persons must be protected. The most effective protections healthcare providers offer patients are built on the foundation of a caring and committed therapeutic relationship.
For patients whose illness tends towards self-destruction, and for patients whose suffering is rooted in social conditions like loneliness, a physician-assisted death option will crack that relational foundation. Current evidence shows that vulnerable persons will fall through that crack. That's why it's always a good idea to consult with a reliable therapist in order to get additional help. Even if you are not in Canada, you can always find top Los Angeles therapists that suit your needs.
The committee, in its wisdom, expressed confidence that physicians would be able to figure this out. Hopefully, as lawmakers draft legislation in the days ahead, deeper wisdom will prevail.
Dr. Harvey Max Chochinov is a distinguished professor of psychiatry at the University of Manitoba and an expert advisor with EvidenceNetwork.ca. He holds the only Canada research chair in palliative care. He led an external panel, appointed by the federal government, looking at legislative options to Carter v. Canada.