One of the most complex issues facing physicians today is whether a physician is permitted or even obligated to assist a suffering patient to shorten his or her life — a process often called “medical assistance in dying (MAID)” or “physician-assisted suicide.”
Until recently, this contentious issue applied only to patients with incurable conditions who may seek to end their pain and a physician is called upon to facilitate that objective. In the United States, that’s the population who might avail themselves of that option.
New proposed legislation in Canada — the country with the largest number of physicians-assisted deaths — would expand the categories of people eligible for MAID to include those with serious mental illness. Originally set be passed in March 2023, the law has been deferred for final decision until March 2024.
A commentary by Dinah Miller, MD, published on Medscape, explores the implications of this proposed legislation for psychiatrists.
“To offer the option of death facilitated by the very person who is trying to get [patients with serious mental illness] better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide,” Miller writes. “As psychiatrists, do we offer hope to our most vulnerable patients, or do we offer death? Do we rail against suicide, or do we facilitate it?”
The piece garnered much reader attention, with numerous laudatory comments: a “nuanced and open-ended inquiry here,” “timely and honest,” and “beautifully written.” One reader thanked the author for “this thoughtful, questioning, and open reflection on what it means to be a psychiatrist facing a thorny and deeply personal practice and philosophical question.”
Non-Psychiatric Illnesses
Many readers were opposed to any type of physician involvement in hastening death, whether the condition is medical or psychiatric. “Let others who wish to die make their own arrangement without the aid of the medical profession,” one declared.
But others felt that, for people with terminal physical illnesses or intractable pain, there was justification to either facilitate the death process or, at the very least, withhold life-prolonging treatments.
A critical care physician described responding to families’ accusations that withdrawal of life-sustaining measures means “playing God.” On the contrary, the physician writes, “there is a limit to our abilities; and withdrawing those life-prolonging interventions allows nature or God or whatever to play a role and take its course.”
Another reader pointed out that “multiple polls in this country have shown that the majority of the general public, physicians in general and psychiatrists in particular, support the option of MAID for the terminally ill. They do not find it at variance with their calling as physicians.”
Cognitive Distortion or Objective Reality?
Many felt that not only physical illness but also the prospect of cognitive degeneration — specifically dementia — was also justification for assisting a patient in terminating his or her life.
“I and many of my elderly friends don’t fear death but fear prolonged dementia with its dependency and lack of quality of life,” a reader opined. “We would be much more at peace if we could put in our advanced directive that we request MAID once some point of dependency has been reached.” Another wrote: in the event of entering a state of “degrading dependency and hardship on the family, please let me go peacefully, without burdening others, into that good night [of death].”
A Canadian reader noted that provisions for advance consent are now in place in her country for people who are facing the prospect of neurodegenerative disease and are still mentally competent to make such decisions.
But therein lies the rub: the concept of an advanced directive goes to the question of decisional capacity. Miller writes: “Depression distorts cognition and leads many patients to believe that they would be better off dead and that their loves ones would be better off without them.”
The concept of “cognitive distortion” implies that the illness itself may impede the decisional capacity required for an advanced directive or a decision made in the moment, in the absence of such a directive.
Miller asks, “How do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope?”
One writer attested to this from personal experience. “As both a physician and a sufferer of severe, often profound depression for 50 years, I can confidently say that…the pursuit of death is the result of an impaired mental state, which simultaneously prevents a rational decision.”
Another agreed. “As a psychiatrist, I treated suicidal patients almost every day of my 27-year career. I believe in making every effort to prevent the suicide of a healthy depressed person and I do not support MAID for psychiatric conditions. But I do support MAID for the terminally ill.”
Other readers disagreed. In the words of one commentator, “I think that if we are going to help mentally ill people, we have to consider their choices. The stress imposed by a severe/intractable mental illness is as bad as any other devastating medical illness. If no one is going to hold their hand in life (as support services are limited and psychiatric treatments often fail), allow a medical professional to hold their hand through their final moments.”
A psychiatrist described very ill patients with bipolar disorder who had been treated not only with medications but with electroconvulsive therapy and ketamine but did not respond. “Their suffering is enormous and the truth is that there is no improvement for more than a few days or weeks and later they return to their hell. Appreciating that they would be better off dead for themselves and their families is not always a cognitive distortion but an objective evaluation of their reality.”
And — as a reader pointed out — an issue with the argument presented here is that it presupposes that MAID requires “clinical justification.” But in Canada, “MAID…is understood as an expression of personal autonomy. Rooted in liberal political philosophy of individualism…approval for death need not be based on a clinical assessment.” Instead, “death is seen as a ‘right’ that the state must therefore provide.”
Another Form of Eugenics?
Miller raised a concern regarding the potential for racial and socioeconomic factors to create further ethical implications of MAID for those with psychiatric illness.
“Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death?” she queries. “Do we risk facilitating a patient’s demise when other options are unavailable because of a lack of access to treatment or when social and financial struggles exacerbate a person’s hopelessness? Should we worry that psychiatric euthanasia will turn into a form of eugenics where those who can’t contribute are made to feel that they should bow out?”
Several readers agreed. “Looking at the disproportionate burden of illness, rates of imprisonment, and application of the death penalty indicates to me that race and socioeconomic status will be an immediate factor in how, where, and with whom MAID for mental illness would be practice in much, if not all, of the US,” wrote one physician.
A Canadian reader seemed to confirm this concern. “I’ve seen a handful of people, including someone I considered a good friend, opt for MAID because it was easier than living as a disabled person in poverty without adequate mental health care.”
On the other hand, offering people good care can make all the difference, according to another Canadian reader. “As a Canadian mental health clinician who served youth with severe mental illness for over 20 years through our socialized medical network, I can attest to the difference good care usually makes in shifting clients from despair and a commitment to death to embracing life once again. Let’s not, as clinicians, embrace easing a government/state-sanctioned pathway to death.”
No Simple Answers
Some readers felt that these types of issues can’t be discussed in a vacuum and each case is different. “Real life is always more complicated than academic discussions,” one wrote. “Having served on a hospital ethics committee, I know that each case is unique.”
Another reader added, “I think all we can do as physicians is to let people decide for themselves and participate only if our conscience allows.”
Batya Swift Yasgur MA, LSW is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).
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