Medical Assistance in Dying: Challenges for Psychiatry

Medical Assistance in Dying (MAiD), which comprises euthanasia and medically assisted suicide, is practiced in a growing number of countries and jurisdictions. In countries where it is permitted, the individual who requests it must be experiencing severe pain and suffering, but not all countries require the individual to be terminally ill. In some countries the suffering may be caused by a mental disorder in the absence of physical illness or disease. The consideration of mental illness as the sole indication for MAiD is likely to be considered in more jurisdictions. However, the ethical duties of a doctor to promote health, reduce suffering and protect life may conflict with one another when viewed from the perspective of MAiD. Arguments in favour of including mental illness as a sole qualifier for MAiD include the respect for the autonomy of the individual, and the equivalence of mental illness with physical illness. Arguments against, include the view that the protection of life is paramount, and the “slippery slope” of ever more permissive practices that fail to protect the vulnerable in society. Given the ethical and other practical concerns, there is a need for psychiatric bodies internationally to provide guidance on this issue.

The WPA has not formally adopted a position on MAiD as applied to psychiatric conditions. The Madrid Declaration (12) however is of relevance, as it addresses euthanasia, stating (emphasis added): Euthanasia: A physician's duty, first and foremost, is the promotion of health, the reduction of suffering, and the protection of life. The psychiatrist, among whose patients are some who are severely incapacitated and incompetent to reach an informed decision, should be particularly careful of actions that could lead to the death of those who cannot protect themselves because of their disability. The psychiatrist should be aware that the views of a patient may be distorted by mental illness such as depression. In such situations, the psychiatrist's role is to treat the illness.
The Madrid Declaration emphasizes three medical duties: to promote health, relieve suffering and protect life. A number of jurisdictions and medical bodies accept that in terminal illness, when death is imminent (see table), the relief of suffering and respect for a competent wish to die supersedes the ethical duty to protect life. However, in considering MAiD in non-terminal disorders, these duties may be seen to be in conflict with one another. The mental illness that might rarely be seen as meeting end of life care criteria is likely confined to a small group of persons with intractable anorexia nervosa for whom their mental illness can result in serious medical sequelae similar to conditions seen in end of life cases. Outside this, mental illnesses are not terminal (13). Should the suffering caused by symptoms of serious mental illness ever justify MAiD? Should other psychiatric bodies nationally or internationally develop policy positions ahead of such debates? To assist this, we wish to briefly summarize the ethical debates for and against this position.

ARGUMENTS AS TO WHY MENTAL ILLNESS MIGHT QUALIFY FOR MAID Autonomy vs. Paternalism
There is little doubt that serious mental illness can be a painful, irremediable and severe illness that causes great suffering. Treatments may be only partially effective, and may result in side effects intolerable for the person. For some the prognosis for relief of symptoms is poor and, despite symptoms of their illness impairing aspects of their function, the person can still competently evaluate their treatment options and chances of their recovery. Autonomy is the fundamental right for competent adults to self-determination. Under this principle, a competent decision to end one's life in order to relieve one's own suffering, provided it is made rationally and without external influence, is justifiable. Persons with lived experience of serious mental illness may view this as their autonomous wish that physicians should respect, and failure to do so reflects continuing medical paternalism.

Equivalence With Physical Illness
To differentiate between treatment resistant medical illness and treatment resistant mental illness is a false division, and reflects stigma. Indeed, there is a small but growing literature on "palliative" mental health care that asserts the need to recognize that current treatments, acceptable to the person, will still leave the person suffering and, that as with some physical illnesses, recovery or cure is not obtainable (14).

Protection of Life Is Paramount
The APA and RANZCP positions on this issue emphasize that there is a profound ethical duty of a doctor that cannot be reconciled with participation in the killing of a patient. That some persons with mental illness will die by suicide is a fact that all practicing clinicians are aware, and there can be respect for the person's wish to suicide, but not for participating in or facilitating it.
Although it is accepted that mental illness may be irremediable in some cases, and doctors have a duty to relieve suffering, they have little ability to predict who will suffer unremittingly and who will recover partially or fully. There are also palliative treatments and other approaches to relieve suffering. For patients, that which seemed to be overwhelming may eventually change and become tolerable. Doctor's opinions as to the patient's prognosis and competence to make this irreversible decision may be prone to error, not based on scientific evidence, and based on the values and moral judgment of the individual the doctor.

The Slippery Slope
There is a duty for doctors to protect the most vulnerable in society. There is a risk that practices are prone to abuse, and that there is a "slippery slope" of ever more permissive practices that will fail to protect those who are most in need of protection (15). Patients must have confidence in the medical profession, and there is risk of erosion through physician's involvement in roles that may be seen to be at odds with their duty to treat illness and promote health.

CONCLUSION
Given the above ethical concerns and rate at which these laws are being considered and reports of some significant problems encountered in countries where it has been adopted, there is a need for psychiatric bodies internationally to consider and provide guidance about how to respond to the question, "Should MAiD extend to serious mental illness?", and for these questions to debated and carefully considered within the broader psychiatric community.

AUTHOR CONTRIBUTIONS
RJ and AS co-authored and edited the manuscript.

FUNDING
This work was supported in part by an Academic Scholars Award to Dr. Jones from the Department of Psychiatry, University of Toronto.