Assisted Suicide and Mental Illness – Where Do You Stand?

Image by Gerd Altmann from Pixabay

By Marvin Ross with commentary by Dr David Laing Dawson

Numerous countries throughout the world (including some US States) allow for medically assisted death for people who are suffering. The original Canadian legislation contained the caveat that the person requesting must have death as an imminent reality to qualify. The individual had to be competent, agreeable and have 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. That left out those whose lives met all of those criteria save for imminent death and  those with mental illness.

This past September, the Quebec Superior Court struck down the imminent death section and gave the government six months to amend the law. Once the amendments are in place (consultation with the public are ongoing and government has requested an extension), assisted suicide will be open to all who meet the strict criteria including those with mental illness.

The inclusion of mental illness is causing considerable debate and there have already been cases where those with mental illness have taken their own lives in private because they could not be granted assistance. Andre Picard, in the Globe and Mail, cites a woman in Quebec suffering with intractable bipolar disorder who finally resorted to suicide by putting her head in a plastic bag and crawling into the trunk of her car.

In a letter sent to media just before she took her own life, she wrote “People with cancer can die with dignity and be comforted, surrounded by their loved ones. A person with mental illness must die alone, in the trunk of her car. I so badly wanted to be accompanied and helped.” As Picard wrote Véronique Dorval, a 38 year old biochemist, suffered from bipolar disorder, which she described as a “cancer of the soul.” Medication provided little relief from her suffering, and debilitating side effects.

In Windsor, Ontario, Adam Maier-Clayton attempted for quite some time to be given the right to die with dignity because of the terrible suffering he was experiencing as the result of :

generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, depersonalization disorder and psychosomatic pain that was “just horrible,” a burning in his eyes, head, biceps, chest and elsewhere.He and his father said they tried everything —including medications, counselling and experimental treatments —but nothing worked.”

When he could not qualify for assisted suicide, he checked into a motel alone, and ended his life by overdose.

The arguments against allowing suicide for mental illness patients, according to Picard are that “It is impossible to determine if a mental illness is irremediable, and vulnerable patients will be encouraged to die because of a lack of mental health services or evil-doers who want to rid society of people with disabilities.” Both are not valid says Picard. In the Netherlands that has a very liberal law, fewer than 1% of patients who take this route suffer with mental illness.

Udo Schuklenk who holds the Ontario Research Chair in Bioethics at Queen’s University in Kingston, Ontario and who chaired the Royal Society of Canada International Expert Panel on End-of-Life Decision-Making, also wrote supporting assisted suicide in the Globe. He went through all the arguments used by the opponents and disproved them.

The point of view of a practicing psychiatrist in Dr David Laing Dawson is the following:

I think assisted suicide for refractory mental illness presents three very difficult issues to consider.

Most chronic and debilitating physical illnesses have been so well studied, researched and documented we, or experts in each field, know with a degree of certainty the inevitable course of the illness and whether or not all known effective treatments have been utilized.

For e.g. we know where ALS leads; we know there are no effective treatments beyond the palliative; we know and can see objectively, the suffering entailed in the progression of this disease.

But for bipolar disorder or schizophrenia, for example, the patterns of symptoms and the course of the illness, and the responsiveness to treatment, are almost as variable as the number of people with these illnesses. How do we ensure, when the request for Assisted Death is made, that the course of the illness from this point is predictable and that all known treatments have been tried and failed? And if resources are available to make such a determination and/or to carry out another new treatment plan?

The second problem is making a determination that the request for assisted death is not, in itself, a symptom of the illness. Or of a co-morbid untreated severe depression.

The third problem lies in the transactional nature of the request. That is, for all of us at times, and for some people with certain personality disorders all the time, any such demand or request or statement is driven by transactional needs, such as the need, at this moment in time, to be able to assume or fight for power/control in the current relationship.

A highly contentious topic and I would love to hear what readers of this blog have to say on the issue. Feel free to wade into the debate.

6 thoughts on “Assisted Suicide and Mental Illness – Where Do You Stand?

  1. This is not a simple or easy issue. I definitely favor euthanasia in cases of unremitting, unstoppable suffering. The examples provided by Mr. Ross seem to be cases where assisted suicide should be allowed. Yet the issues Dr. Dawson describes are real. I think I would condone assisted suicide for the mentally if a preponderance of the evidence indicated that the individual was lucid, suffering without hope of cessation and every available avenue for remission had been attempted.

    While the vast majority of us mentally ill can have our lives greatly improved by the best care theoretically possible, availability, affordability and awareness are persistent problems. At what point should we allow drastic action to end suffering?

    Liked by 1 person

  2. Thank you for posting this toughtful piece. Let me make a few comments on the (valid) points Dr Dawson raises. His first concern pertains to the question of the degree of certainty anyone can have vis a vis the irremediableness of the illness. Leaving aside that certainty doesn’t come in degrees, this is a fair point. I’m not a regulator, but nothing would stop regulators from insisting that all available treatment modalities (in their health care system) must have been tried by patients in order to become eligible for MAiD. Once those options have been exhausted (and I know from personal experience that that point is reached at some point in time by some patients), the irremediableness question takes a different turn. It then asks whether the disease would truly be irremediable during the patient’s lifetime. How can anyone know? That is something no one can know, but it should be up to decisionally capable patients to decide whether or not they’d like to bide their time and wait. Many will have that strength, and they ought to be supported as good as is feasible. Others will choose not to subject themselves to potentially decades of uncertainty and suffering they consider unbearable. They should be able to make the decision on whether they’d like to opt for MAiD themselves, and as a society we ought to respect and support that decision. None of that suggests that the lives of people with refractory mental illness are not worth living by some objective standard. It simply means that we as society respect the considered choices decisionally capable patients with such illness make for themselves. If they, on reflection, do not consider their lives worth living, and our health care system has no other treatment modalities to offer, it seems callous to disregard both their decision, and ultimately, their suffering.

    Dr Dawson is concerned about decisional capacity. Capacity assessments take place in our health care systems all the time. The same standards should apply to patients with mental health issues, or else their rights as citizens are severely undermined. Because these diseases do not lead to imminent death, we have sufficient time for such assessments to be made, and also to ensure that a given patient’s request to access MAiD remains consistent over time.

    Liked by 1 person

    1. Food for thought, though there are so many questions around the thorny issue of the right to invoke MAID, and when (after how long the suffering has persisted.), etc.?

      When one is afflicted with an unrelenting mental illness that causes so much intense suffering on an often on-and-off, sometimes intense, basis, it is not easy for professionals to know when, or “if,” to assist in death. Freedom of choice is not so clearly cut when the illness controls the thinking. That aside, intense suffering is just that, but the issues are very complicated for many who are seriously mentally ill. I have often heard patients who have stabilized say “Why was this treatment not given before? I should have been forced, etc..” I could go on with lots of examples.

      I note that you speak of “decisionally capable patients,” and also that the death-wish must remain consistent over time, presumably before proceeding to MAID. The problem is that, unlike many other illnesses, the organ-of-decision-making has been compromised by the illness, and it is sometime difficult to evaluate that function is clear and capable.

      I have known many who have been literally tortured by their illness for long periods of time, years sometimes. But then a different intervention has been employed and quality of life has truly been restored an acceptable level, and the situation changes dramatically.

      As for Capacity Boards, many ill individuals go through many of them and evade treatment until restorative treatment is eventually made compulsory. I have known one individual go through nine of these. The net result in that case was quality of life was restored and maintained for years.

      However, I admit that some are really at this time treatment refractory, even when there is access to proper healthcare. Professionals making the decision to aid in death of these sufferers have a serious problem. This is not a task for the faint hearted.


  3. Unalterably opposed. Given individuals what to commit suicide committing suicide is not that all that difficult now. Assisted suicide for the mentally would indeed place all kinds of pressures on the mentally ill to commit suicide. The next stop would be gas chambers.


  4. Elon Musk says yes , ‘I will give you a weekend seminar on how to build rockets.’ and you attend. Bill Gates says ‘I will give you a weekend seminar on how to build a software company’ and you attend. A top psychiatrist says ‘I would be happy to talk to you about the treatment of schizophrenia. Some of my very best patients do not work, stay home are very depressed and are quiet’ then you figure someway to get prescriptions and stay out of the system. Bye


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