Canada is in the middle of a vigorous debate about whether incurable mental illness is grounds for Medical Assistance in Dying. This has been approved by Parliament, but public reaction forced the government to delay implementation until 2024.
In a sensitive and eloquent essay in the online magazine Psyche, a Belgian psychiatrist, Marie Nicolini argues that “it is difficult to see how we can ethically justify ending the lives of people with mental illness”. Amongst her concerns are the following.
The definition of “incurable” or “intractable” is fuzzy and ambiguous. “In a comprehensive review of scientific research on the curability of depression, my colleagues and I found that there is no objective standard of incurability for clinicians to hold on to. The commonly used term ‘treatment-resistant depression’ typically means that a patient has had two unsuccessful trials with antidepressants; it is not a synonym for ‘incurable’.”
She points out that a long history of symptoms does not necessarily mean that a patient cannot recover: “prediction accuracy is, at best, at chance level – like flipping a coin.”
There is a serious social justice issue – the gender gap in euthanasia. There is a “consistent finding that among people receiving euthanasia for mental disorders, 69 to 77 per cent are women. In my team’s study of Dutch psychiatric euthanasia cases, 36 per cent had a history of severe sexual or other kinds of abuse. Gender-based violence is a major public health issue that affects one in three women worldwide, and for which mental healthcare and prevention are lagging. When there is evidence that a policy, particularly one that involves ending lives, may reflect or deepen pre-existing inequities, that should give us pause.”
Clinicians’ biases pose a risk to patients. “For example, euthanasia guidelines direct clinicians to assess how ‘palpable’ they find their patients’ unbearable and hopeless suffering. In the Dutch cases we studied, clinicians used the label ‘palpable suffering’ almost exclusively with regard to patients with personality disorders. This is troubling because it is well known that clinicians often view people with personality disorders negatively, as ‘difficult’ or ‘hopeless’ individuals.”