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Gillian Deichmann

Kitamura

English 1010

9 December 2022

Literature Review: Physician-Assisted Death for Psychiatric Patients

Introduction

Physican-assisted suicide has been a pertinent topic within the last several years; it is

described as an end-of-life procedure for people experiencing painful suffering from a terminal

illness. Many countries have passed laws to allow medically-assisted deaths with strict

requirements. These restrictions usually include that a person's condition is irremediable and

their end is reasonably foreseeable. Recently, there has been a discussion on whether psychiatric

patients have the right to apply for physician-assisted suicide. Canada's new C-7 Bill, allowing

this procedure for individuals with mental illness, has caused heated controversy.

The controversy lies within three main topics. The first is if people with psychiatric

disorders can make life-altering decisions. The argument is whether the decision is influenced by

their mental illness or is competent and rational. Another topic argued is how allowing this

measure for psychiatric patients will affect how the public responds to suicide. The last issue I

will discuss is whether mental illness can be irremediable. In this paper, I will review multiple

pieces of literature to further expand the knowledge behind physician-assisted suicide for

psychiatric patients. Evaluating these topics should create a more comprehensive perspective on

whether individuals with mental illness have a right to physician-assisted death.

Competency
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One main issue with the conversation is competency. Whether a person with a mental

illness can make a life-ending decision without the influence of their illness, many argue that this

decision is solely a symptom of the psychiatric condition. In contrast, others say that the

evidence is too convoluted to conclude if a person with a mental illness can make such a

decision. Some insist that psychiatric patients can make life-altering decisions, and they already

do.

Some argue that psychiatric patients have already been making life-altering medical

decisions. Law and medicine professor, Dalhousie Health Law Institute member, and

neuroethical researcher Jocelyn Downie partnered with Justine Dembo, a psychiatrist and

licensed physician, to write the article "Medical Assistance in Dying and Mental Illness under

the New Canadian Law." This article heavily emphasizes that "persons with mental illness can be

capable of making decisions with respect to their health - even where the consequences of the

decisions are death." (Downie and Dembo 3). Here, the authors argue that psychiatric patients

can make life-altering decisions; for example, medically-assisted death. They mention how

people with mental illness have been making these decisions for many years. Downie and

Dembo describe a case with an anorexic patient and how the doctors allowed "the patient to

refuse life-sustaining treatment on the grounds that she was highly likely to die from the illness

and that her suffering was unbearable" (3). This shows how a person with a psychiatric condition

was allowed to refuse treatment and choose death because the suffering was intolerable, and she

was likely to die. Downie and Dembo use this case to insist that people with mental illness

already make possible life-ending decisions.

Further, others would add that there is a difference between a desire to die and a rational

decision to end one's life due to suffering and decreased value of life. Ryan Tanner, writer of "An
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Ethical-Legal Analysis of Medical Assistance in Dying for Those with Mental Illness," has a

Ph.D. in philosophy and bioethics. He is also a member of the joint Centre for Bioethics Task

Force on Medical Assistance in Dying. Tanner says, "There is a difference between a suicidal

desire that is a feature or symptom of depression, and a desire for death rooted in a person's

assessment of their circumstances in suffering from depression." (167). He implies that a person's

choice to receive a medically-assisted death is not irrational and not one made lightly. It is a

decision that takes time to come to and is not easy.

However, the issue may rely on the ability of a physician or psychiatrist to determine if

the patient's decision is competent. Tanner mentions, "The 'hazard,' however, lies in a perceived

inability to determine the authenticity of vulnerable patients' wishes, like those of patients with

mental illness." (169). The author argues that the problem is not whether a patient can make such

a decision but whether the professional can decipher if the decision is legitimate. He goes as far

as to say that "we may fail to protect some patients with mental illnesses from pursuing an

inauthentic, ingenuine decision to die." (169). Tanner's point is that there is a significant risk that

some people with mental illness will slip through the system without proper evaluation from a

professional.

Overall, all of the authors have different points of view regarding an individual with

mental illness's capability to make decisions to end their lives through physician-assisted suicide.

Some say that it is nearly impossible to decipher the authenticity of the request, while others

would insist that an individual with mental illness has already been making these decisions.

Public Policy

Another topic heavily discussed when discussing physician-assisted suicide for

psychiatric patients is how the public's view will change through these new laws. There is much
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discussion on whether it will negatively impact the professionals taught to prevent suicide at all

costs. Several sources argue that the prevention of suicide will decrease with the advancements

in physician-assisted death for psychiatric patients. Others say that the public has difficulty

understanding the differences between physician-assisted death and a person taking their own

life; they state that this incorrect use of dialogue changes the perspective on the topic.

The first step to differentiating between suicide and physician-assisted death (PAD) is to

change the dialogue. Scott Y.H. Kim is a bioethics physician, a senior investigator for the

Department of Bioethics, and a psychiatric professor. Kim and other authors wrote the article

"Suicide and Physician-Assisted Death for Persons with Psychiatric Disorders: How Much

Overlap?" that describes the importance of altering the dialogue people and suicide prevention

organizations use to help society understand the difference between PAD and suicide. Kim et al.

state, "One of the most concerning are how the practice of psychiatric PAD will affect the

longstanding societal commitment to preventing suicide. It should give us pause when a leading

suicide prevention organization minimizes this problem while ignoring the evidence that

psychiatric PAD is difficult to distinguish from suicide." (1100). Society has committed to

preventing suicide at all costs. Kim et al. imply that if the evidence-based dialogue is unavailable

to the public and suicide prevention organizations, differentiating between a rational death and

an irrational one will be difficult for people to understand.

Allowing medically-assisted death for individuals with mental illness could contradict a

professional's commitment to preserving life. Franklin G. Miller, Ph.D., is a Senior faculty

member at the Department of Bioethics, National Institutes of Health. He co-wrote

"Physician-Assisted Death for Psychiatric Patients - Misguided Public Policy" with Paul S.

Appelbaum, a licensed psychiatrist at Columbia Psychiatry and a well-known expert in ethical

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problems in psychiatry. Their article discusses how allowing people with psychiatric conditions

could go against what police, physicians, and psychiatrists stand for. They explain that there are

"significant differences between a legal option for physician-assisted death limited to patients

with a terminal illness and one that permits such assistance for patients with serious mental

disorders who are not terminally ill" (Miller and Appelbaum). A person with a terminal illness is

likely to die from their condition, while a person with a mental illness is not. They argue that it is

already difficult for physicians to hasten the passing of a terminally ill individual; therefore,

allowing assisted deaths for mental disorders could further strain the commitment made by

professionals.

Further, authorizing physician-assisted death for an individual with mental disorders

could become a substitution due to the lack of resources for sufficient treatment in certain

countries. Mark Komrad, a psychiatrist for John Hopkins Hospital and writer for Psychiatric

Times, wrote the article "Oh, Canada! Your New Law Will Provide, Not Prevent, Suicide for

Some Psychiatric Patients." Here, he explains how many psychiatrists have spent decades

preventing suicide and that allowing physician-assisted deaths for individuals with mental illness

is counterintuitive. There is fear that "euthanasia could become a cost-saving alternative to

suffering when adequate solutions are not available or affordable." (Komrad). In other words, the

author is arguing that by allowing human euthanasia for people with mental illnesses, it will be

used as a cheaper alternative for those who are in the lower income bracket.

Ultimately, the subject of public policy when describing physician-assisted suicide for

psychiatric patients includes many different aspects. The central discussion in the public policy

section is how medical professionals will be affected and whether it contradicts what they stand
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for. Another factor is how society's perception of suicide will change with new laws being

implemented.

Curability

The conversation on the curability of mental illness is emphasized throughout various

articles. Many argue that most mental conditions are treatable and that PAD is unnecessary due

to the constant advancements in new treatments for psychiatric patients. Others say that their

mental illness can be incurable and that people should not make psychiatric patients suffer longer

than they have to. The majority of this discussion is around the irremediability of

physician-assisted deaths.

Some argue that certain mental illnesses can be incurable. Downie and Dembo discuss

curability throughout their paper and how not all mental illness is treatable. They make note that

"[a]lthough psychiatric treatment continues to advance, there remains a significant proportion of

patients who do not recover despite high-quality psychiatric care." (Downie and Dembo 4). Here,

the authors say that even though there are new advancements in medicine every day, there will

still be patients who do not respond. They indicate that the number of people who either relapse

or never recover is more prominent than many think. They believe that psychiatric conditions,

like depression, obsessive-compulsive disorder (OCD), and borderline personality disorders,

have high incurable or relapse rates.

There are previous circumstances where psychiatric patients' treatment goals get switched

to a more palliative approach. Many treatments cause more suffering than they are worth. The

authors further their argument by claiming that with each failed procedure comes even more

invasive and intense therapies that are "detrimental to their quality of life" (4). Downie and

Dembo explain that "with each failed treatment attempt comes further demoralization on the part
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of patients and their families." (4). The authors indicate that the quality of life of an individual is

more important than trying to fix the issue.

Others argue that some mental illnesses considered "untreatable" or "incurable" are

misconceptions. Lars Mehlum, Ph.D., is a psychiatrist, psychotherapist, and the founding

director of the National Centre for Suicide Research and Prevention. He partnered with several

other authors to produce the paper "Euthanasia and Assisted Suicide in Patients with Personality

Disorders: A Review of Current Practice and Challenges - Borderline Personality Disorder and

Emotion Dysregulation." This paper discusses the evidence and implications of the data for

physician-assisted suicide for psychiatric individuals, explicitly focusing on borderline

personality disorder (BPD). Mehlum et al. claim that BPD is not incurable, even though many

believe so. They mention that it is a long-term illness challenging to cure but not as nearly

impossible as many find. The authors describe that various innovative treatment options are

"effective with medium to large effect sizes and remission achievable in a high percentage of

cases" (6). This quote means that specific treatment options are successful for people suffering

from BPD. Mehlum et al. strongly argue that there is a misconception that BPD is not curable

due to the public's lack of knowledge regarding the treatment options that increase the quality of

life for individuals diagnosed with BPD. At the very least, Mehlum et al. urge legislation to

reevaluate the criteria and include that all treatment options are exhausted before

physician-assisted suicide is allowed for mental illnesses.

In the end, curability is a complex topic that includes various moving parts. Many believe

all treatment options should be tried before physician-assisted death is considered. While others

would argue that the more procedures one forces someone to receive is demoralizing and

decreases the quality of life.

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Conclusion

In summary, physician-assisted death for people with mental illness is not a

black-or-white topic. It consists of many layers. The C-7 bill signed in Canada will be enacted in

2023, and many worry about the subject's consequences and ethics. The issue touches on

whether a person with mental illness can make such decisions when a symptom of most mental

illnesses is suicidal ideation and how clinicians can decipher if the request is rational. Others

argue that allowing medically-assisted death changes how society and medical professionals

react to suicides. Several say that the chance of curability for mental illness is too significant to

allow such procedures; on the other hand, a few insist that mental disorders can be irremediable.

This literature significantly impacts society and alters the perspectives of many.

Physician-assisted suicide is already a sensitive subject for several, so discussion about allowing

it for mental illnesses creates another layer of complexity. This information could change how

mental illness is viewed by society and the perspective of preventing it--allowing more

conversation about whether some assisted deaths are justifiable. It could change how clinicians

handle situations where psychiatric patients are not responding to treatment. It opens the door to

whether excluding people with mental illness from this procedure is discriminatory or if it is the

act of protecting and preserving life.

Further Inquiry

A topic that needs to be researched more in-depth is if people with intellectual disabilities

should have access to physician-assisted deaths. There are very few details on whether a person

with an intellectual disability, like autism, could receive the procedure. It would be interesting to

see if the criteria changes and how the decision could be made. This conversation could give

light on what constitutes suffering and if people have the right to tell others how bad their
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suffering is. It would also add information on who has the right to have a medically-assisted

death and who does not.

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Works Cited

Downie, Jocelyn, and Dembo, Justine “Medical Assistance in Dying and Mental Illness under

the New Canadian Law” Benchmark, 2016, pp. 1-9,

https://jemh.ca/issues/v9/documents/JEMH_Open-Volume_Benchmark_Medical_Assista

nce_in_Dying_and_Mental_Illness_Under_the_New_Canadian_Law-Nov2016.pdf

Kim, Scott Y H, et al. “Suicide and Physician-Assisted Death for Persons with Psychiatric

Disorders: How Much Overlap?” JAMA Psychiatry, U.S. National Library of Medicine, 1

Nov. 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394825/.

Komrad, Mark S. “Oh, Canada! Your New Law Will Provide, Not Prevent, Suicide for Some

Psychiatric Patients.” Psychiatric Times, 1 June. 2021,

https://www.psychiatrictimes.com/view/canada-law-provide-not-prevent-suicide.

Mehlum, Lars, et al. “Euthanasia and Assisted Suicide in Patients with Personality Disorders: A

Review of Current Practice and Challenges - Borderline Personality Disorder and

Emotion Dysregulation.” BioMed Central, BioMed Central, 30 July 2020,

https://bpded.biomedcentral.com/articles/10.1186/s40479-020-00131-9.

Miller, Franklin G., and Paul S. Appelbaum. “Physician-Assisted Death for Psychiatric Patients -

Misguided Public Policy” The New England Journal of Medicine, 8 Mar. 2018,

https://www.nejm.org/doi/full/10.1056/NEJMp1709024.

Tanner, Ryan “An Ethical-Legal Analysis of Medical Assistance in Dying for Those with Mental

Illness” Alberta Law Review, vol 56, no.1, 2018, pp. 149-176,

https://albertalawreview.com/index.php/ALR/article/view/2500/2482
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