Physical pain is only one consideration. For those with severe mental illness yet who are still capable of choosing, assisted death must be an option.
I became a psychiatrist because I value life, deeply. I value the search for meaning in every kind of life, and I am in awe of the fact that every single person I encounter is entirely unique. I cherish every glimmer of progress in treatment, and I mourn the fact that I cannot help everyone — and that modern medicine, wonderful as it is, cannot help everyone.
Did I expect to help people end their lives when their suffering becomes unbearable? Until I was in medicine, the idea of unmitigated suffering was just that: an idea. Only through medical training did I see that this idea was, to my horror, a reality. I still struggle to come to terms with that reality.
I was already proud to be Canadian when it became possible for autonomous individuals who are capable of medical decision-making to access medical assistance in dying (MAiD) when they have a serious incurable illness, disease or disability; when they are in an advanced state of irreversible decline in capability; when they are experiencing enduring and intolerable suffering that cannot be relieved under conditions acceptable to them; and when their natural death has become reasonably foreseeable. I became prouder when the Quebec Superior Court struck down the “reasonably foreseeable natural death” criterion so that patients who could be facing decades of intolerable suffering can have the same option.
I am dismayed, though, to think that this same right might not be afforded to persons experiencing enduring, unbearable suffering from a mental illness that has not responded to a large number of high-quality treatments and social interventions. I am dismayed at recent commentary that suggests persons with mental illness should not be permitted to exercise their autonomy because they are more vulnerable than persons with physical illness. This implies that they should not be permitted to decide for themselves how much suffering is too much. It also implies that persons without mental illness are always less vulnerable. But severe pain, nausea and existential suffering toward the end of life can also lead to vulnerability.
Psychological suffering is as unbearable as physical pain, if not more so. I see it in front of me on a regular basis. Patients with both physical and mental illness tell me that they would choose the physical pain over the mental agony in an instant. Also, psychological and existential suffering are considered valid eligibility criteria for MAiD for persons with physical illnesses; in a recent Canadian study, a high proportion of patients receiving MAiD reported both physical (99.5 percent) and psychological (96.4 percent) suffering. How can we acknowledge the burden of those forms of suffering in some groups of patients but not in others?
Yes, mental illness can affect the way persons see themselves and the future. Absolutely, not everyone with mental illness is capable of decision-making. And absolutely, most mental illness is treatable. I can understand some people’s fears that in a struggling mental health system within an unequal society, patients will ask for MAiD because they have not been able to get the help they need. But asking for MAiD does not mean automatically receiving MAiD. And if such a patient requests MAiD, they may then see a psychiatrist for the first time — a psychiatrist who takes their desperation seriously and carefully evaluates their eligibility — and they may gain access to better care as a result. In my clinical experience assessing requests such as these, this is what often happens. Also, in my experience, some patients requesting MAiD have had access to high-quality mental health care within the public system. Others have had no financial barriers and have had treatment in both the public and private sectors, over a span of decades, and yet still suffer intolerably. Fortunately, these patients are in the minority. We can help most people to gain a quality of life they deem satisfactory, and to find meaning even when it has seemed lost for years. And we work as hard as we can to make this possible.
Unfortunately, we cannot help everyone to the point where they find their quality of life to be acceptable when they assess it themselves — and this is something only they can know, because it is subjective. We do not question this subjective sense of suffering as often with physical illness; this is a product of stigma, in my view. We accept the fact that modern medicine cannot alleviate all suffering in the physical realm; I worry when psychiatrists cannot accept this fact in the psychiatric realm.
I struggle to find the words to express how terrible it is to face this fact. And yet it is the reality. How do we deal with this reality, as individuals and as professionals?
The law contains eligibility requirements and procedural safeguards that protect vulnerable people, including those with mental illness. It requires that patients requesting MAiD not be coerced, either by others or by their socio-economic circumstances. The law also requires that the illness be “irremediable”: this means that treatments have been made available and tried, without providing sufficient relief. Additionally, the illness and suffering must be “enduring”: a person who is experiencing an episode of depression for the first time, who is at an acute risk of suicide or who is grieving over a sudden loss would not qualify.
It is true that irremediability is defined with respect to treatments considered acceptable by the patient. Some authors worry that this means assessors will proceed with MAiD when a patient experiencing first-time mental illness decides to refuse even first-line treatments. This is where another safeguard, capacity, comes in. Patients must be considered capable with respect to the MAiD decision: this means they possess the ability to understand all of the facts relevant to the decision, to appreciate how those facts apply to them, to reason and to articulate a clear choice. Capacity can certainly be questioned if a patient is refusing basic, non-invasive treatments.
As a MAiD assessor who attempts to ensure that no stone has been left unturned, I am distressed that some of my colleagues might think I would approve MAiD without being certain that a patient is capable of the decision, or without ensuring that all reasonable resources and treatments have been offered. How could anyone imagine that assessors and providers would take such requests lightly?
In a perfect world, we would cure all suffering; but in this imperfect world, we should be humble enough to acknowledge that we cannot. I certainly hope that we do everything in our power to improve access to high-quality health care and to prevent suicide while also honouring the wishes of persons suffering unbearably from severe illness who are capable of choosing for themselves.
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