{"id":293382,"date":"2016-03-23T17:34:39","date_gmt":"2016-03-23T21:34:39","guid":{"rendered":"https:\/\/policyoptions.irpp.org\/2016\/03\/assisted-suicide-mental-illness-competence-consent\/"},"modified":"2025-08-28T15:26:29","modified_gmt":"2025-08-28T19:26:29","slug":"assisted-suicide-mental-illness-competence-consent","status":"publish","type":"post","link":"https:\/\/policyoptions.irpp.org\/fr\/2016\/03\/assisted-suicide-mental-illness-competence-consent\/","title":{"rendered":"Assisted suicide, mental illness, and the competence to consent"},"content":{"rendered":"

Canada<\/a> has recently established the right to physician-assisted suicide, and Canadians\u00a0are debating who should have\u00a0that right. In\u00a0Carter v. Canada<\/em> (2015)<\/a>, the Supreme Court held that it was unconstitutional to<\/p>\n

prohibit physician-assisted death for a competent adult person\u00a0who (1) clearly consents to the termination of life and (2) has a grievous and\u00a0irremediable medical condition (including an illness, disease or disability) that causes\u00a0enduring suffering that is intolerable to the individual.<\/p><\/blockquote>\n

The Court did not limit\u00a0this right to those who are near death. After all, if a person has a right to suicide to escape intolerable suffering during\u00a0the last days of her life, why should she be forced to endure it for decades? Nor did the court exclude any specific medical condition. This raises the question:\u00a0Should\u00a0the right to assisted suicide be extended to persons who want to end the\u00a0suffering they experience from\u00a0mental illness<\/em>?<\/p>\n

It is entirely appropriate for Canadians to discuss whether\u00a0persons with\u00a0mental illness would be competent to consent to a physician-assisted suicide.\u00a0Liberal societies\u00a0believe that all citizens are entitled to the equal protection of the law. So if a right is granted to one class of citizens, and the boundaries of that class are arbitrary, we should knock that\u00a0barrier down.<\/p>\n

But is it arbitrary to exclude\u00a0patients who want an assisted suicide to end a mental illness?\u00a0Mental illness is associated with a high risk of suicide<\/a>. Moreover, there are significant concerns about the physician-assisted suicides of psychiatric patients in the Netherlands<\/a>, where the practice is legal\u00a0(see also here<\/a>).\u00a0We need to think carefully about who is competent to consent to an assisted suicide.<\/p>\n

The Court gave the Canadian government a year (since extended) to write\u00a0laws and regulations implementing physician-assisted suicide. From the\u00a0Carter <\/em>decision, we can see that physicians will be able to\u00a0assist the suicides of\u00a0competent adults\u00a0with irremediable and enduring conditions that cause intolerable suffering.<\/p>\n

So, can\u00a0the suffering of severe mental illness be\u00a0intolerable<\/em>? In his classic memoir of his depression, Darkness Visible<\/a><\/em>, William Styron wrote that<\/p>\n

The pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne.<\/p><\/blockquote>\n

Can severe mental illnesses be irremediable and enduring<\/em>? Yes: some\u00a0patients suffer\u00a0incurably. However,\u00a0many cases have an episodic course, with\u00a0suffering that is irremediable but not necessarily enduring. It is an open question whether psychiatrists can accurately distinguish\u00a0cases in which the suffering will remit from those that never will.<\/p>\n

Are psychiatric patients competent to consent<\/em>? Even some severely\u00a0mentally ill\u00a0people can be\u00a0competent to make important life decisions. Nevertheless, we should\u00a0be extremely careful\u00a0about the competence of psychiatric patients to consent to assisted\u00a0suicide.<\/p>\n

Mental illness is the\u00a0strongest<\/a> known risk factor for suicide.\u00a0Danish researchers<\/a> linked a national registry of psychiatric patients to vital statistics data. They found that adult men with mental illnesses are more than 12\u00a0times more likely to die by suicide than the general population and women are more than 13\u00a0times more likely.\u00a0These exceptional ratios are\u00a0why preventing suicide is the first priority of mental health clinicians. Further, the epidemiology of suicide\u00a0poses this question:\u00a0Is\u00a0the desire of a mentally ill person to take his life a reasonable response to his situation or a symptom of his disease?<\/p>\n

Legal\u00a0competence<\/a> requires that a person be\u00a0able to appreciate his\u00a0situation and its consequences. However, hopelessness is both a key symptom of depression and an important indicator of suicide risk. Styron:<\/p>\n

It is hopelessness even more than pain that crushes the soul.<\/p><\/blockquote>\n

A person can be\u00a0hopeless because she has\u00a0accurately appraised her\u00a0future. But the mentally ill\u00a0often underestimate and devalue their prospects. Styron wrote about his illness that<\/p>\n

The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will comenot in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow.<\/p><\/blockquote>\n

Or so he felt\u00a0at the time<\/em>. Yet after that\u00a0episode, Styron\u2019s\u00a0condition remitted. He experienced\u00a0a final relapse<\/a> at the end of his life. But a midlife suicide would have cost him and his family many healthy years, and it would have cost the world Darkness Visible<\/a><\/em> and A Tidewater Morning<\/a><\/em>.<\/p>\n

The Canadian Parliament is working on the law required by the Supreme Court. The Parliament\u2019s\u00a0Special Joint Committee on Physician-Assisted Dying<\/a> recommended<\/p>\n

That individuals not be excluded from eligibility for medical assistance in dying based on the fact that they have a psychiatric condition.<\/p><\/blockquote>\n

The Committee cited the argument of the distinguished ethicist and lawyer Jocelyn Downie<\/a> that<\/p>\n

[M]ental illness should not be an exclusion criterion [for assisted suicide because]… not all individuals with mental illness are incompetent. Physicians already routinely determine whether someone is competent, even when they have a mental illness.<\/p><\/blockquote>\n

Physicians do routinely make competence determinations. This is because these determinations have<\/em> to be made and there is no reason to think that anyone else can do a better job of it. However, those aren\u2019t strong grounds for\u00a0believing that physicians can validly and reliably<\/em> determine when a desire to end one\u2019s life is a reasonable decision and when it is a symptom of mental illness.<\/p>\n

In an assisted-suicide competence determination, a physician can make two kinds of errors. On the one hand, she could judge that a patient is incompetent to consent, when in fact he is. If so,\u00a0the cost is that the patient will be deprived of his\u00a0rights. On the other hand, the physician could judge that the patient is competent to consent, when in fact he is not. If so, the cost\u00a0is a dead patient. We have no estimate of the likelihood of either type of error<\/em>. The Canadian\u00a0parliamentarians have confidence\u00a0in physicians\u2019 abilities to determine whether mentally ill people are competent to consent to assisted suicide. But this confidence lacks a scientific foundation.<\/p>\n

Concern for the autonomy and dignity of the mentally ill means that we should\u00a0urgently develop valid procedures for determining which patients are competent to consent to assisted suicide. Concern for their lives means that we should precede incrementally and not include mental illness until we\u2019ve worked this out.<\/p>\n","protected":false},"excerpt":{"rendered":"

Canada has recently established the right to physician-assisted suicide, and Canadians\u00a0are debating who should have\u00a0that right. In\u00a0Carter v. Canada (2015), the Supreme Court held that it was unconstitutional to prohibit physician-assisted death for a competent adult person\u00a0who (1) clearly consents to the termination of life and (2) has a grievous and\u00a0irremediable medical condition (including an […]<\/p>\n","protected":false},"author":913,"featured_media":293380,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"content-type":"","ep_exclude_from_search":false,"footnotes":""},"categories":[],"tags":[8450,8446],"article-status":[],"irpp-category":[],"section":[],"irpp-tag":[],"class_list":["post-293382","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","tag-assisted-dying-fr","tag-mental-health-fr"],"acf":[],"yoast_head":"\nAssisted suicide, mental illness, and the competence to consent<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/policyoptions.irpp.org\/fr\/2016\/03\/assisted-suicide-mental-illness-competence-consent\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Assisted suicide, mental illness, and the competence to consent\" \/>\n<meta property=\"og:description\" content=\"Canada has recently established the right to physician-assisted suicide, and Canadians\u00a0are debating who should have\u00a0that right. 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