This article originally appeared in Canadian Affairs.
By David Zitner, March 6, 2024
Should doctors kill mentally ill patients who wish to die?
The rise of medically assisted death (MAID) has ignited intense debate, particularly concerning its extension to include mental health problems. While palliative sedation and end-of-life care have long been accepted norms, hastening death for individuals with mental health concerns raises serious ethical quandaries and practical implications.
Context is essential. There are historical precedents where medical interventions, such as the champagne prescribed to Russian playwright Anton Chekhov as he lay dying in 1904, were aimed at easing discomfort without raising ethical eyebrows. But the advent of MAID introduces a new dimension, where the line between alleviating suffering and hastening death becomes dangerously blurred.
Traditionally, palliative sedation, a form of medical assistance in life, has been integral to end-of-life care, focusing on improving quality of life for terminally ill patients. However, the premise of MAID diverges, advocating for the deliberate acceleration of death to pre-empt potential future suffering — a concept laden with ethical complexities.
Advocates of extending MAID to mental health conditions argue that unbearable suffering, whether physical or psychological, warrants the option of a dignified death. But the criteria for MAID eligibility in Canada — requiring a serious, incurable disease with intolerable suffering — raise questions as to whether those standards apply to mental health.
Unlike physical ailments with predictable trajectories, mental health conditions lack objective markers for prognosis, complicating assessments of eligibility for MAID.
There is little evidence that mental health practitioners understand, any better than the rest of us, motivations for death. Nor can they reliably predict which patients will continue to prefer death, not life, or which individuals will eventually recover from severe depressed states.
Moreover, the inherent subjectivity of mental health diagnoses raises even more ethical quandaries about the use of MAID: Can mentally ill patients make informed decisions about their end-of-life care? What if they have undiscovered medical illnesses that might be treatable with regular medical care?
In Canada, where medical professionals serve as gatekeepers for assessing eligibility for MAID, concerns about the potential for coercion or undue influence loom large. The lack of empirical evidence regarding clinicians’ ability to accurately predict which patients are truly suicidal, or whether mental health treatments may work in the long run, underscores the risks of extending MAID to such cases. While some individuals may claim they want to die during acute mental health crises, many ultimately find meaning and purpose in life with appropriate support and treatment.
The rush to embrace MAID for mental health concerns mirrors past missteps in health care, such as aggressive gender-affirming therapies, where long-term outcomes remain uncertain. Moreover, the irreversible nature of MAID makes it impossible to conduct post-mortem evaluations of its efficacy or potential harms, underscoring the need for caution and robust evidence before extending it to the mentally ill. Without rigorous safeguards in place, there is a risk of unintended consequences, such as exacerbating stigma surrounding mental health or undermining efforts to promote resilience and recovery.
Furthermore, the erosion of personalized health care in favour of bureaucratic solutions reflects a troubling trend towards impersonal end-of-life care. Many Canadians do not have access to a personal family doctor. Instead, they rely on clinics with protocols that apply to many people but may not be appropriate for everyone. In the absence of markers, predicting the persistence of a patient’s death wish becomes nearly impossible. Meanwhile, institutional culture and the beliefs of individual doctors can strongly influence clinicians’ receptivity to assisted death as a solution to mental health problems.
The Canadian Charter of Rights and Freedoms enshrines the rights to life, liberty and security of the person. This language should not confer an entitlement to physician-assisted death. Rather than rushing into policies that end the search for solutions to mental health problems and seemingly prioritize expedience for patients and clinicians over compassion, policymakers and medical professionals must prioritize holistic, individualized, patient-centred care that upholds the dignity and value of every individual’s life.
Extending MAID to include mental health conditions raises profound ethical and practical quandaries that demand careful consideration. While the alleviation of suffering is a noble goal, the risks of unintended consequences and ethical dilemmas cannot be overlooked. As society grapples with these complex issues, a balanced approach that respects the autonomy of individuals while safeguarding against harm is crucial in navigating the ethical quandaries of MAID.
Dr. David Zitner is a senior fellow at the Macdonald-Laurier Institute. He has participated at every level of Canadian health care including clinical practice, research, administration, governance and patient and professional education.
