Peter J. Baylis critiques the argument that mental health concerns are never irremediable, and that people with a mental illness as a sole underlying condition should not be eligible for medical assistance in dying.

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In February 2020 Dr. John Maher, published an opinion piece titled “Why legalizing medically assisted dying for people with mental illness is misguided”. To me, the article seems embroiled in passions informed by a career tending to the emotional needs of others. As an addiction and mental health clinician (PhD social worker) with 30 years of service in the field, I understand and feel similar passion. But at the same time I believe the arguments supporting Maher’s position are not strong enough to prevent all mental health patients from accessing medical assistance in dying (MAiD).

Maher’s position suggests all “mental illnesses” are treatable. He says “every single person with severe mental illness can experience dramatic improvement in their symptoms and concomitant reductions in their suffering”. According to this view, their condition is never irremediable and therefore never eligible for MAiD. However, by extension the following equally applies: every single person with severe “mental illness” might not experience any improvement and may significantly deteriorate as their suffering increases and does not remit. The hubris of overconfidence in the effectiveness of treatment risks being a cornerstone of treatment futility, which aggrandizes a field at the expense of others’ suffering.

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Most branches of medicine recognize death is a possible outcome of many disorders regardless of the treatment offered. Yet according to some practitioners death is never a possible outcome for psychiatric concerns. If death occurs, it is due to ignorance, neglect, or not creating a safe enough environment for the patient for a long enough period of time. Perhaps upholding the belief in an ever-present, though at times elusive, remedy for all mental suffering maintains the field’s value and integrity. Accepting death as a possible outcome of mental health concerns understandably risks eroding hope in the process of care. However, hope’s focus should not be limited to the preservation of life at all costs. Even with the best medical care, people die as a result of illness. Hope resides with the patient, though it plays out in their relationship with a care giver, and the patient’s hope may not be limited to prolonging their life regardless of its quality.

Again, one argument to deny individuals access to MAiD whose sole underlying medical condition is a mental health concern, is the position that no mental health concerns are irremediable. They may be grievous and cause great suffering, but they are all treatable.  This grand position seems reliant on anecdotal experience and suggests the science guiding the field is of limited value in the face of personal experience. This is problematic for a field whose epistemology is rooted in positivist science, encouraging critique and bracketing personal bias. Regardless of the limits of the current state of the science (there are many), we know that many people experience lifelong challenges with mental health concerns. We know that many people struggling with mental health concerns experience unbearable suffering, and we know that many take their own life in response to such suffering.

A recent publication by Lippard and Nemeroff, and various other studies exploring the long term effects of adverse childhood events, speak to the protracted nature of mental health challenges associated with exposure to such events. Mental health concerns can become irremediable conditions and frequently occur concurrently with serious medical illnesses, both of which can cause unbearable suffering. We need to acknowledge and confront the limits of our science related to the practice of mental health care, allowing competent adults opportunities to decide where they want to place their faith and fate in the management of their emotional well-being. Though I remain conflicted about MAiD in response to unrelenting suffering caused by a mental health concern, I cannot deny all such persons the right to determine how they wish to address their suffering. At this time, the government of Canada’s proposed changes to the Criminal Code provisions on MAiD (Bill C-7) seeks to exclude eligibility for all individuals suffering solely from a mental health concern. Full parliamentary review has yet to occur.

An individual suffering with an irremediable mental health concern poses a challenge to the integrity of the field of psychiatry. Perhaps practitioners feel a need to be viewed as having the ability to relieve the suffering of their patients. In psychoanalytical terms, this need becomes a confirming narcissistic reflection in the service of the ego. The patient’s suffering gives rise to the caregiver’s identity. Death does not provide this service to the ego, but nor should the unremitting and unbearable suffering of a patient.

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Peter J. Baylis is a clinical supervisor in Addiction and Mental Health Services for Alberta Health Services.