Daryl Pullman examines the argument that prohibiting medical assistance in dying for people whose sole underlying condition is mental illness unfairly exceptionalizes mental illness.
Since the introduction of legislation to permit medical assistance in dying (MAiD) in Canada, there has been steady pressure on the Federal government to expand the eligibility criteria so more people can access this service more easily. Indeed the Federal government is poised to eliminate the requirement that a person’s death must be reasonably foreseeable. The Senate has proposed that an amendment banning MAiD for those who suffer from mental illness but who have no other underlying physical ailment, should only be in effect for 18 months. The Trudeau government supports a 24 month ban, after which people whose sole underlying condition is mental illness would be eligible for MAiD. I believe the arguments for expanding eligibility to people with mental illness are ethically problematic.
Those who advocate for extending MAiD to persons with mentally illness as a sole underlying condition draw upon two central arguments. The first is referred to as the problem of mental health exceptionalism. Generally this argument states that it is wrong to treat mental illness exceptionally, that is, as if it is different from other kinds of health issues. Doing so can lead to the stigmatisation of those who suffer from mental illness and may lead to unjustifiable discrimination against them. Denying MAiD to the mentally ill is supposedly guilty on both counts. The second argument draws on the patient’s autonomous right to self-determination. Like any other individuals, competent persons who suffer from mental illness have the right to make health care decisions for themselves. Denying them this right, including the right to choose MAiD, is again, on this view, a case of unjustifiably exceptionalizing their illness.
While it is certainly true that some (perhaps most) types of mental illness exceptionalism should be avoided, we should not ignore material differences between mental illness and physical illness that are particularly relevant in discussions about MAiD. Most importantly is the fact that mental illness is almost never the direct cause of death for those who suffer from it. While it may be the proximate cause for some who become suicidal due to their mental illness, standard medical practice with such patients is to intervene to prevent their deaths, not to provide assistance for the suicidal act.
It will be argued, of course, that not all who suffer from mental illness are suicidal. Indeed, those who are suicidal as a direct result of their illness are generally not considered capable, and would thus not be eligible to request MAiD in the first place. It is rather those capable individuals who suffer from chronic mental illness and who find the prospects of going on with life in this condition unbearable, who, on this view, should be afforded the right to MAiD. However, inasmuch as such individuals do not suffer from a physical illness, they supposedly have the physical capability to end their lives without medical assistance. To argue that these individuals should be granted a positive right to a medically assisted death, even though the cause of their unbearable suffering is their mental illness, is to exceptionalize mental illness in a different way. Other physically capable individuals who for whatever reason find their current life situation intolerable such that they would prefer death over continued existence, have only a negative right to suicide. That is, no one has a duty to assist them if they choose to go that route. Allowing MAiD for mental illness would exceptionalize mental illness among all other reasons physically capable individuals might choose to commit suicide.
Either we must avoid exceptionalizing mental illness by creating a positive right to MAiD for anyone who for whatever reason finds their current circumstances unbearable, or we should continue to limit access to MAiD to only those who have an underlying qualifying physical condition. The latter option exceptionalizes mental illness, but the former effectively medicalizes suicide by making it a positive right for everyone, not only those who suffer from mental illness.
Denying access to MAiD to those suffering from mental illness exceptionalizes them when compared to people with physical illnesses, but this is an ethically defensible exception. It would, however, treat people with mental illness like any others without a qualifying physical ailment, but who nevertheless find life unbearable. For all such individuals we extend our love, our care and our compassion with the goal of sharing their burden and keeping them among the living.
Daryl Pullman is Professor of Bioethics in the Faculty of Medicine and Director of the Centre for Bioethics at Memorial University.