Assisted Dying, Mental Illness, & Patient Age

Ellen Wiebe, a physician who has provided medical assistance in dying, discusses her views about providing this service when the request is from a young person suffering from mental illness.

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Earlier this year I assisted the only person in Canada known to have received medical assistance in dying primarily for suffering caused by mental illness. The patient, identified as EF by the Alberta Court that granted her permission to access medical assistance in dying, died peacefully in Vancouver on June 1, 2016. She was surrounded by friends and family. The four judges who heard her case, her family doctor, and I had no hesitation in respecting her right to end her suffering.

A few weeks later, on June 16, “An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying)” received Royal Assent. According to the Act, people are eligible for medical assistance in dying as long as they meet all of the following criteria:

(a) they are eligible … for health services funded by a government in Canada;

(b) they are at least 18 years of age and capable of making decisions with respect to their health;

(c) they have a grievous and irremediable medical condition;

(d) they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and

(e) they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.

The Government and others who oppose euthanasia have said that patients whose sole underlying condition is a mental illness do not qualify for medical assistance in dying under the Act. Not everyone agrees with this interpretation, however. Some suggest that patients whose sole underlying condition is a mental illness could meet the criteria set out above.

Wheat Field in Rain (1889) Vincent Willem van Gogh

Wheat Field in Rain (1889) Vincent Willem van Gogh

Since the passage of Bill C-14, I have assessed a number of people requesting assisted death for primarily mental health reasons. Like EF, they have unbearable suffering from a grievous and irremediable medical condition. Like her, they have seen many doctors and had many treatments, but nothing has worked to end their suffering. Like her, they are clearly capable of making medical decisions.

Although I was so sure about EF and so willing to help her, I have not felt the same about most of the young people that I have assessed. I recognize that their suffering is unbearable. I see that they have tried various therapies and taken many drugs without experiencing relief for their suffering. And yet, I cannot bear to be the one to end their lives. Do I think young people should suffer more and longer than older people? No. Do I think that they are going to get better some day? Maybe. In my lifetime, I have seen young people whose cases seemed hopeless and yet they went on to have satisfying lives. Do those few anecdotes have any relevance to those who are suffering? Not really.

Most of the time I see assisted dying as a basic human right and as an important part of good, complete medical care. If we are thinking about rights, then people with a primary mental illness deserve just as good and complete care as people with a physical illness. As such, they should have the right to an assisted death. Young people should not be discriminated against because of their age.

And yet, we must and we can protect those whose mental illness causes them to lose decision-making capacity and, as a result, become a danger to themselves and others. This is done every time people are forced into hospital to be treated against their wishes. This is the right thing to do, so that these people can heal and then be able to make decisions for themselves. We can use the same determinations of capacity to decide if patients with mental illness are able to make a sound decision about assisted death.

I believe that Canada should allow persons with mental illness to access medical assistance in dying, provided the following conditions are met:

(a) the mental illness has been present for at least 5 years;

(b) the patient has tried evidence-based psychotherapy provided by at least 2 therapists;

(c) the patient has tried evidence-based drug therapy involving adequate doses of at least 5 different drugs at different times; and

(d) three doctors (one of whom is a psychiatrist) have assessed the person and agreed that she is eligible for medical assistance in dying.

Whether I would be comfortable with providing medical assistance in dying for young people with mental illnesses under these guidelines, I don’t know.

My mentors from the Netherlands have said that they must be personally convinced about the merits of each case they participate in and I agree with them. I must be personally convinced that assisted death is the right option if I am to provide the service.

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Ellen Wiebe is a Clinical Professor in the Department of Family Practice at the University of British Columbia and Medical Director of HemlockAID.