Euthanasia and assisted suicide, also labeled “Medical Aid in Dying” (MAID), have been popular topics in the field of medical ethics for several decades. Typically, the conversations surrounding this subject have limited the definition of the terms as assisting in death of patients who are suffering and terminally ill. In the few areas of the world where this medical practice is legally permitted, it usually is restricted to those with a terminal illness. As if this concept has not been controversial and emotive enough, Canada’s senate passed a bill, C-7, on March 17th, 2021, to further expand access to assisted suicide to patients with psychiatric disorders such as depression and personality disorders. Of course, there will be boundaries to this expansion. A 2-year interval after the passing of the bill is being used to concretely and specifically define the criteria which a mentally ill individual should meet in order to be eligible for MAID. It seems the right to MAID is planned to be extended to those suffering solely from mental illness that is “grievous and irremediable.” The ethical dilemma to be discussed here is autonomy vs nonmaleficence.
Before officially practicing medicine, many clinicians make the Hippocratic oath to “be of benefit and do no harm.” In Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (2015), nonmaleficence is defined as contributions to the health of the patient “that prevent further injury or reduce its risk.” We’ve learned that generally, nonmaleficence trumps autonomy. This concept is easy to understand when discussing examples like a patient that requests to amputate a completely healthy leg; obviously a healthcare provider would deny this request because of the principles being discussed. However, the ethically correct decision in the case of MAID in severely depressed patients is not as clear, and whether nonmaleficence trumps autonomy in this situation is cloudy. Yet, despite the complications regarding this dilemma, nonmaleficence should ultimately still trump autonomy. In the context of physician-assisted dying, Clinical Ethics (2015), notes that no one should be forced to endure unbearable suffering and that ethically, a physician may perform euthanasia in efforts to respect their autonomy and relieve them of their pain. This may be the argument of proponents of this new law. Yet, this book also states that before going through this procedure, a physician “should be confident that the patient has decisional capacity, is not clinically depressed, and is suffering from a condition that can realistically be characterized as terminal.” Therefore, it is clear that this law should be repealed because ethically, MAID should exclude those that solely have a mental illness and should be reserved only to those that have a terminal illness. There is also the argument from proponents of C-7 that says excluding the mentally ill population from the right to choose MAID is discriminatory against those with psychiatric disabilities. To this point, I would contend that prohibiting euthanasia from mentally disabled individuals actually advocates for this community, as providing this option to the population somewhat suggests that the life of a mentally ill person may not be worth living. MAID may be irresponsibly used against these patients if it is seen as an easier, more cost-efficient ‘solution’ compared to extensive treatments.
I’m curious to see what specific protocols and guidelines will be determined during this 2-year interval after the passing of Bill C-7. What constitutes as an irremediable mental illness? What list of psychiatric treatments needs to be exhausted before allowing this? While there is no argument that people living with severe mental illness should not be required to bear through unnecessary suffering, assisted dying is not the suitable answer here. Rather, every evidence-based, and even off-label, psychiatric treatment should be given a real shot. Healthcare providers are ethically obliged to be healers in the presence of their patients’ lives, especially those without terminal illnesses, as every human should be given the opportunity to live their life to its fullest potential.
References
Bryden, J. (2021, March 17). Senate passes Bill C-7 to expand access to medical assistance in
dying | CBC News. https://www.cbc.ca/news/politics/senate-passes-medical-assistance-
dying-billc7-1.5954281
Jonsen A.R., & Siegler M, & Winslade W.J.(Eds.), (2015). Clinical Ethics: A Practical
Approach to Ethical Decisions in Clinical Medicine, 8e. McGraw-
Hill. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx? bookid=1521§ionid=88812622
