On assisted death and psychological suffering

This column was published at Maclean’s on March 28, 2017

In 2015, a landmark ruling by the Supreme Court of Canada struck down the federal ban on physician-assisted suicide, solidifying the charter right of competent, consenting adults who are “suffering intolerably as a result of a grievous and irremediable medical condition” the right to die on their own terms with medical assistance.

Criminal prohibition on assisted-death, the unanimous Carter v. Canada decision noted, condemned the “grievously and irremediably ill … to a life of severe and intolerable suffering. A person facing this prospect has two options: she can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.”

That callous dilemma was rectified only in part by the assisted-dying legislation put out by the federal government in June, which restricts physician-assisted death to “grievous and irremediable” illness where natural death is “reasonably foreseeable.” In effect, the law prohibits assisted-death beyond the end stages of terminal disease, a limit that defies the underpinnings of the Carter ruling and fails to provide medical professionals with straightforward criteria or substantive guidance on this delicate matter.

The instinct to prioritize extreme physical suffering above all else is a deeply human tendency. Even without first-hand experience, people can relate to tangible pain. Compassion is natural. But abstract torment—the sort of ongoing suffering caused by an unquiet mind—garners far less empathy and even scarcer latitude. However unsettling it is to discuss, it is time for honest, open dialogue to begin on the matter of physician-assisted death for psychological disease.

Where the government’s narrow approach to assisted-dying has sown confusion and doubt around patient eligibility and physician liability, the distinct exclusion of psychological suffering further compounds uncertainty, as it inadvertently establishes an hierarchy of disease and opens the extent and validity of another’s suffering to broad debate. When the legitimacy of an illness can be arbitrarily called into question, people living with proven-irremediable torment will be denied their charter right to die simply because their anguish stems from a disrespected diagnosis.

The government will at some point, by choice or by force, amend its assisted-dying legislation which, in its current form, has been deemed unconstitutional by Peter Hogg, Canada’s foremost authority on constitutional law. When the required independent review regarding the scope of eligibility reports back in 2018, a comprehensive understanding of mental illness will prove crucial to making the law right.

Though significant gains have been made in demystifying mental illness and eroding the stigma attached to various diagnoses, there remains a reluctance to candidly discuss, or even admit to, an uncomfortable reality: As is the case for any severe or chronic health condition, for some, recovery from mental illness simply will not happen—not for lack of effort or will, mind you, but because the brain cannot right itself. Be it unrelenting depression or ruthless OCD, psychiatric disorders which prove not-responsive-to-treatment can, like a terminal cancer, slowly destroy the individual without mercy and without reprieve.

A point will be reached where there is little, if any, quality of life, and deterioration will only continue. It will not get better because in those specific, extreme cases, it cannot get better. Though painful to confront, this truth cannot be ignored. It’s key to understanding the true nature of mental disease.

To date, medical conversations around aid in dying have largely omitted this component of psychological illness. In arguing against assisted-death for psychiatric suffering, Euthanasia Prevention Coalition (EPC) president Jean Echlin insists: “If somebody loses their life now, they’re put to death, and two weeks from now there’s a breakthrough, they’ve lost their life when they could have had quality.”

But that’s a false premise. In making that argument, the EPC and similar organizations appeal to a misplaced faith in some imminent, miraculous recovery. They endlessly debate what if scenarios because they refuse to acknowledge the distressing reality of what is.

Forcing someone to exist for decades in what amounts to an excruciating purgatory is no morally or ethically superior than granting those living a ceaseless hell some control over their circumstance by allowing the option of a merciful end should they, at some point, choose.

Because, to be clear, these individuals will end the pain. Bioethicist Udo Schuklenk, who chaired the Royal Society of Canada’s 2011 panel on end-of-life decision-making, confirms “a large number” of those suffering from intractable mental disease will “at one point or another commit suicide, and it often happens in terrible circumstances”; these methods often further traumatize those left behind. Physician-assisted death offers “a better way for them to end their lives,” and provides a peaceful, controlled conclusion, where no loose ends remain to painfully fray. In this sense, state-facilitated “suicide” is a form of harm-reduction.

There’s understandable apprehension about “normalizing” suicide or being seen as encouraging—or worse, glorifying—death over treatment and recovery for psychiatric suffering. But suicide and assisted-death are two entirely different phenomena and should not be confused.

As the Centre for Suicide Prevention notes, suicidal urges are temporary and the act itself is one of desperation. At their point of crisis, a suicidal person “cannot see alternatives to their situation beyond death.” They do not want to die, but they lack the means to help them live. “Given help,” the CSP says, “they will choose help”; with proper intervention, recovery is not only possible, it can be expected.

Those qualifying for assisted-death explicitly want to die. They have sought and exhausted all available medical resources, and further treatment would not yield results. With no prospect of recovery or further improvement, their decision to die would be neither rash nor ill-considered, but carefully planned and, if carried out, done so mindfully.

A proper framework for assisted-death in cases of physiological suffering would see final approval granted to those who undoubtedly qualify while safeguarding the most vulnerable. Stipulating alternative pathways be encouraged throughout the screening process and mandating meetings with medical and psychiatric professionals who would offer the proper course of treatment to those who perhaps, to that point, had gone without or were unable to access it could, over time, save lives.

The right to assisted-death needn’t supplant or replace proper mental health funding and treatment, either. Where already available, in cases of terminal disease, aid in dying doesn’t replace or supersede comprehensive palliative care, but serves as an option in addition to it.

An excruciating life voluntarily cut short is undeniably tragic. So too is condemning others to an unending misery because the distress of those uninvolved—over the mere notion of an alternative—is deemed the greater bother.

 

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