The federal government committee looking at physician assisted dying released its long-awaited recommendations recently to much debate. The permissive approach it recommends reflects the spirit of the Supreme Court of Canada declaration that the prohibition of physician assisted dying violates the fundamental human right to make one's own decisions about one's bodily integrity and medical care.
The Supreme Court also ruled, and the committee accepted, that Canadians should not face a cruel choice between intolerable suffering and a violent or dangerous self-inflicted death.
But what concerns many is the committee recommendation that those enduring psychological suffering due to mental illness should also be eligible for medical aid in dying.
Why the concern? Physician assisted dying is not a real 'choice' for those with mental illness if we don't first offer them adequate care and support. And the unfortunate reality is that, in Canada, mental health is vastly under-serviced.
One of the consistent worries voiced throughout Canada's long national discussion of physician assisted dying is the desire to protect vulnerable people. One fear is that people with disabilities may be directly pressured or coerced into consenting to medical aid in dying.
More insidiously though, vulnerable people may come to desire death due to a lack of any reasonable alternative to their suffering.For this reason,many have called for us to redouble our attention to providing access to high quality palliative care so that people are not driven toward medically assisted death by uncontrolled pain.
With the committee inclusion of psychological suffering due to mental illness as a condition eligible for physician assisted dying, we must ask the same question about access to high quality mental health care and social support. How can we offer one as a 'choice' without the other?
Here, it is worth returning to the Supreme Court of Canada's declaration in another case that "the mentally ill have historically been the subjects of abuse, neglect and discrimination in our society." This neglect has resulted in "years of under funding of mental health," in the words of the Mental Health Commission of Canada.
An article published earlier this month in JAMA Psychiatry reviewed 66 cases of medical aid in dying provided to people with psychiatric illnesses in the Netherlands between 2011 and 2014. The review found that most of these cases were women (70 per cent) with chronic severe conditions, and 56 per cent were described as socially isolated or lonely. As Dr. Paul Appelbaum commented in an editorial accompanying the article, these results raise "the concern that physician-assisted death served as a substitute for effective psychosocial intervention and support."
The recently released government committee report recognizes this concern, recommending generally that the government support the Mental Health Commission of Canada's pan-Canadian mental health strategy. However,the primary attention appears to be how to ensure appropriate mental health services are available for people who are requesting medical assistance in dying.
Attention to mental health care and social supports must begin well before a person reaches this point.
Interestingly, the impact of people with mental illness being eligible for physician assisted dying may be to strengthen the argument that we should provide equal concern and resources in Canada for mental as for physical health.
There is currently a systematic stigma in how we organize services and funding for people with mental health problems. For example in 2007, the Wait Time Alliance and the Canadian Psychiatric Association proposed benchmark wait times for access to psychiatric services for people with serious mental illnesses. Yet according to their 2015 report, provinces have yet to even publish wait time data for psychiatric care. In the meantime we have worked hard and succeeded in reducing wait times for hip and knee replacement, cataract and bypass surgery, radiation therapy and diagnostic imaging.
Hopefully the availability of physician assisted dying for people with mental illness will stimulate efforts to make sure that accessible and effective treatments are available for them. Let's hope the committee recommendations will galvanize further innovation to improve medical and social support for some of the most vulnerable among us.
Jennifer A. Chandler is the Bertram Loeb Research Chair and Associate Professor at the Centre for Health Law, Policy and Ethics, Faculty of Law, University of Ottawa. Simon Hatcher is Vice-Chair Research Department of Psychiatry, Faculty of Medicine, University of Ottawa. They are both Members of the Centre for Health Law, Policy and Ethics.
