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  • Emma Benjamin

The Ethics of Ending a Life: Is Psychological Suffering Sufficient Grounds for Assisted Death?

Source: BBC News

The notion of voluntary death is a complex matter that exists somewhere in a labyrinth of social, philosophical, and political perspectives. Because of this issue’s depth, medical assistance in dying (MAiD), or assisted death, has naturally been a contentious point of moral and bioethical debate that has only swelled since the Netherlands were first to legalize it in 2001. Contrary to euthanasia which involves ending a patient’s life at the doing of a second party, MAiD provides medication to patients to self-administer. While both assisted death and euthanasia have sparked concern over such practices being a slippery slope leading to misuse, proponents regard them still as an opportunity for those who are terminally ill and enduring chronic pain to die in dignity and in peace. With increasing acceptance of the latter sentiment over the past 20 years, MAiD and euthanasia are now open to over 200 million individuals across 18 different jurisdictions, most often to those with cancer among other terminal illnesses. The rates for these practices naturally vary from jurisdiction to jurisdiction with the amount of deaths accounted for by these practices ranging from 0.3% to 4.6%. Despite the divide over this practice, however, figures have shown significant increases in cases in places such as Switzerland and the Netherlands over the past decade. These trends have been depicted for four different jurisdictions in the figure below.

Figure by The Lancet

Recently, discourse over MAiD has resurfaced with the proposition of MAiD for a condition less ascertainable than those terminal: psychiatric illness. The expansion of physician assisted death to warrant those with psychiatric illnesses eligible for this practice have been made possible in just four countries thus far, including Switzerland and the Benelux nations (i.e. The Netherlands, Belgium, and Luxembourg). In the past few years, however, similar sentiments have entered North America as Canada sets out to enact the same expansion of their MAiD policy. Though euthanasia for mental illness is now technically legal with the passing of Canada's Bill C-7, which allows those with nonterminal chronic illnesses to be eligible for MAiD, an amendment to permit mental illness as a sole reason for eligibility has been delayed for the March of 2024.

With a serious lack of consensus over euthanasia for psychiatric illness, there have inevitably been a number of concerns regarding these eligibility criteria expansions. One major criticism surrounds the current inability to predict whether a mental illness is irremediable from a more objective standpoint. With one study published in the Clinical Psychological Science journal, it was found that diagnostic recoveries from mental illness averaged at nearly two thirds and ranged from recovery rates of 27.7% to 77.4% depending on the respective illness. A second study from the Journal Psychiatric Services further identified remission rates of approximately one-third for those with lifetime serious mental illnesses along with the observation that recovery rates were seen to increase after 30 years of age. Thus, not only is recovery for serious mental illnesses possible, but treatment might not be as fruitful until later in life for some people. In a CAMH’s statement presented to the Standing Committee on Justice and Human Rights, they further note the insufficient evidence available for psychiatrists to accurately identify the trajectory of a mental illness as doctor’s would for a terminal illness. By this reasoning, they advise against this expansion to Canada’s MAiD until evidence-based criteria for irremediable mental illness is established by experts and those with lived experience of the eligible psychiatric illnesses.

This issue leads to another concern which is whether or not a patient is able to fully consent to euthanasia. Given the breadth of the mental illness spectrum, many wonder if someone with an illness that affects cognitive processes can make the best and most sound decisions for themselves. Cancer psychiatrist Dr. Li acknowledges the difficulty of assessing mental capacity, especially when emotion plays such a significant role in decision-making. Li brings up that MAiD is typically a black-and-white decision for the terminally ill as they have a clear picture of life before and after MAiD. Because someone struggling mentally may be “unduly influenced” by their condition for MAiD, the risk of impulsive suicidality as a patients reasoning for MAiD arises. One study further argues that the degrees of rationality of suicidality–ranging from chronic or consistent death wishes, impulsive or psychopathology-related death wishes, and rational death wishes–have only been slightly differentiated by physicians thus far with a consensus only being met amongst certain groups. The Dutch Association of Psychiatry, for instance, acknowledge those suffering as prone to suicidal ideation that is either impulsive or chronic, the latter of which is more consistent but still a symptom of mental illness. They do, however, believe in the rational definition for a death wish, identifying it in cases where psychiatric illness is directly associated with the patient suffering unbearably without foreseeable improvement. Nonetheless, with no harmony on defining mental suffering and an ambiguous definition for suicidal rationality, further research on these potential criteria is likely needed to ensure eligibility for MAiD is most productive when it comes to mental illness.

The idea of psychosocial vulnerability further complicates the uncertainty surrounding consent for MAiD and even poses the issue of marginalized people being susceptible to this practice. The term psychosocial vulnerability acknowledges the social and economic contexts (i.e. economic class, sexuality, etc.) that might predispose someone to be more susceptible to depression. Individuals are concerned not only of patients themselves seeking to use MAiD as a solution for mental conditions induced by mendable societal challenges, placing a target on already disadvantaged and marginalized people, but also fear that death might replace government action as a solution for such societal issues to some extent. One such societal deficit would be mental health treatment itself. Psychiatrists such as Dr. Stephan Claes and Dr. Joris Vadenberghe, among others, argue that many of the patients who underwent euthanization for psychological suffering weren’t exposed to the vast therapeutic options to their entirety. This becomes an issue when factors such as discrimination or poverty are the main root of their psychological suffering as opposed to an irremediable illness, rendering the approach of improving mental health care potentially ineffective. The possibility that mental illness–a condition that could invoke reason for assisted death–could serve as a veil for such societal deficits like racism or poverty raises an important consideration and reiterates how deeply intersectional this matter is. With MAiD for mental illness being a recent practice, there does remain obscurity over the validity of this concern. The graphs conveying MAiD trends for Belgium and the Netherlands depict this issue, demonstrating not only how infrequent MAiD for psychiatric illness is at this point in time, but also how the rate isn’t necessarily an increasing trend in every region.

The idea that people with psychiatric illnesses are unable to make this decision for themselves is also not universal. Brent Kious and Margaret Battin argue in a 2019 bioethics paper that the episodic nature of mental illnesses such as schizophrenia or bipolar disorder allows for periods of lucidity and remission in which an individual no longer has symptoms. Because of such moments of clarity, Kious and Battin posit that patients retain accurate and “reasonable expectations” of whether or not they will continue to suffer severely with their conditions. More recently, individuals such as the advocacy group Dying with Dignity have condemned pushback against mental illness eligibility for MAiD, deeming it a blatant denial of autonomy and personal choice for those suffering. Brushing off the mentally ill as unfit to make a decision without acknowledging psychological illness for all of its nuances is ultimately a dangerous sentiment to have. Though there is still obscurity surrounding psychiatric patient's ability to consent to a practice like euthanasia, perhaps careful evaluation from a psychiatrist on an individual basis is needed to tackle this issue.

Despite obscure and under-researched metrics for psychological suffering, some also argue that refractory mental illnesses–illnesses unresponsive to two or more treatments–may warrant MAiD in a more objective sense. One study, which surveyed physicians on the appropriateness of assisted death for mental illness, saw a significant increase in agreement with the practice upon viewing three case studies that presented severe examples of refractory mental illnesses. One case presented a 52-pound patient who had suffered from anorexia nervosa for over two decades and no longer wished to further undergo force-feeding. The other cases involved a patient who had dealt with schizophrenia for 16 years and a patient who had experienced suicidal ideation for 20 years; both proved to be resistant to a number of treatments and drugs. From these cases, there appears to be a distinction between acute and more severe psychological suffering even with the lack of metrics. The persistence and severity of each of these cases in spite of treatment resembles aspects of a terminal illness despite the technical inability to quantify psychological pain. With documented refractory mental illness that has been consistently resistant to treatment, one might wonder if an individual who has shown no improvement for a certain period of time could qualify as irremediable eventually.

Ultimately, the decision of ending a life is a delicate topic that requires a high degree of caution before any decisions are made. For one, euthanasia should not be a substitute for societal downfalls (i.e. inadequate psychiatric care) especially given the psychosocial distinctions that render some demographics vulnerable to depression. Though more research is needed to test the validity of this concern considering the insufficient evidence to predict whether expansions in MAiD could disproportionately affect vulnerable demographics, the bill will have irreparable implications once implemented and all possibilities should be thoroughly examined. As CAMH proposed in their statements, the allowance for mental illness to be the grounds for assisted suicide requires thorough and inclusive discussions surrounding this issue. The passage of such an amendment must be an extensive process involving experts and a diverse selection of those with lived experience of mental illness. Thus, even with the persistent lack of consensus on the topic of euthanasia, deliberateness will ensure that careful definitions and metrics are created along with proper safeguards to protect those that are mentally ill and/or marginalized if this amendment does pass in the future.


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