Udo Schuklenk holds the Ontario Research Chair in Bioethics at Queen’s University. He chaired the Royal Society of Canada International Expert Panel on End-of-Life Decision-Making.
Decisionally capable mentally ill patients, who suffer from an irremediable severe condition that renders their lives not worth living in their considered judgment, should qualify for medical assistance in dying (MAID). Why is there even an argument against this?
A close read of the landmark Supreme Court judgment decriminalizing assisted dying suggests they are eligible. The relevant criteria are that the patient is “a competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.” The federal government is currently working on bringing our deficient existing legislation in line with the requirements of that judgment, and asked on Tuesday for a four-month extension in order to get the amendment right.
Well-meaning opponents to the eligibility of mentally ill, capable patients’ access to MAID maintain that treatment-resistant mental-health problems are not actually irremediable conditions, and that with better care, such patients would not seriously consider medical aid in dying.
Timely access to professional specialist care often does prove to be difficult for such patients, and efforts to improve that status quo deserve our support. However, a reality check is in order. A multitude of clinical trials have shown that there is such a thing as treatment-resistant depression, for instance. In the case of major depression, a large study undertaken by the U.S. National Institute of Mental Health reported that 30 per cent of patients did not respond to multiple sequential medication trials, and of those who did respond, up to 70 per cent relapsed within one year. Patients who fail repeated medication trials, hospitalization and psychotherapy often try neurostimulatory treatments. A recent study examining different types of such treatments indicated response rates between 29 to 64 per cent. So yes, there is such a thing as treatment-resistant mental illness. It’s not just a matter of access to services. Psychiatrists pretending otherwise in their public comments on this issue are doing a professional disservice to this difficult debate.
Some may argue these patients should tough it out, and say ending their lives is always an inappropriate answer to their suffering. That decision, however, is one that competent patients should be able to make for themselves. It is not for others to dictate.
An important question, too: What is the quality of life of such patients? Implicit in arguments made by those who might support MAID in severe physical illness, but not in severe mental illness is that suffering the former is much worse than suffering the latter. Another reality check: The intensity of suffering in severe mental illness can be as terrible as that of the most severe physical conditions.
In a large study of subjective well-being, a team of Belgian researchers led by palliative case specialist Jan Bernheim found that only end-stage liver disease (a devastating and imminently lethal condition that only liver transplantation can reverse) was subjectively as severe as mental disorders. Invariably, judgments about our quality of life are subjective, in the sense that they are judgments made by us about our lives. Who else could possibly make that judgment, surely not others who do not actually experience the suffering? We have no reason to think that decisionally capable psychiatric patients’ evaluation of their quality of life is less reliable than that of other decisionally capable patients. People do not decide that they want to end their lives frivolously.
Another argument by anti-choice activists makes much of the supposed vulnerability of psychiatric patients. We are asked to ignore their requests and so protect their vulnerable selves and their human rights. Of course, anyone suffering tremendously from a disease or condition that renders their lives not worth living finds themselves in a position of vulnerability. That is true regardless of whether one suffers from late-stage cancer or treatment-resistant depression.
That, however, does not render anyone decisionally incapable. It is truly a pernicious political strategy to apply the vulnerability label to competent psychiatric patients as a justification for effectively removing their agency. We ought to be concerned about the effect of such rhetoric on years of efforts aimed at destigmatizing mental illness, and indeed on respect for such patients’ human right to self-determination. Patient autonomy deserves to be taken seriously, especially in matters of life and death.
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