Depression and Assisted Death

Last night I read Medical Assistance in Dying: A Patient-Centred Approach. This is the Report of the Special Joint Committee on Physician-Assisted Dying.

In particular, I focused on those recommendations that were related to patients suffering from psychiatric illnesses. Like others in the mental health field, or those who have had loved ones who suffered from mental illness, I am troubled that the report recommends that mental illness shall be sufficient reason to seek Physician-Assisted Death.

I had never expected to be significantly involved in issues related to Physician-Assisted Death as a Child and Adolescent Psychiatrist. Any children or youth diagnosed with a terminal or irremediable physical illness are followed at the Children’s Hospital of Eastern Ontario, the children’s hospital in my region, and not at The Royal, the psychiatric hospital where I work. The majority of psychiatrists would accept that psychiatric patients, including children and youth, would have access to Physician Assisted Death when death because of a terminal physical illness is imminent and their suffering is limiting quality of life. Few of us, on the other hand, would see the illnesses that we treat as terminal, even though people do die because of them. The report also stipulates that those with an “irremediable” condition should have access to Physician Assisted Death, but how do mental illnesses fall into this category?

For psychiatrists, the most common deaths in our practices, suicides, represent a breakdown in treatment. Even when our patients are most depressed, after multiple, different treatments, it is not best practice to decide with them that their condition is “irremediable”. The position of the Canadian Psychiatric Association is consistent with this.

Whenever I see a patient contemplating suicide, they are hopeless and they are suffering but, even though they want to die, they would prefer to feel better. The person, their family, their therapist and I will usually all agree that we are working for that individual’s mental health to improve to the point where death no longer seems the best option. In assessing mental health symptoms in a physically healthy person, the wish to die must first be evaluated as a symptom, not the rational choice made because an illness is terminal or irremediable.

The illnesses that psychiatrists treat are chronic, difficult to control at times but that can be treated to a point where life is not just acceptable but positive and enjoyable. I consider other chronic illnesses: diabetes, hypertension, chronic obstructive lung disease. I believe that most physicians treating these illnesses would believe that it will be difficult for most of their patients to meet the criteria for Physician Assisted Death, so why would my patient with Major Depressive Disorder, Anxiety Disorder, Schizophrenia qualify?

I do not begrudge a person in pain, suffering with a terminal illness, whose comfort will disappear as the illness worsens or death approaches, to consider a comfortable death as an option in their medical care.

Still, I am very concerned that giving my patient this option opens a door that my colleagues and I try desperately to close. Perhaps my concern arises since I see young men and women, on the edge of life, and know that their symptoms mostly improve substantially with treatment. I certainly hope that this issue is being examined by psychiatrists wiser than me. For all that I would ease suffering and pain, where the suffering of depression is concerned, I am still convinced by the poet Dylan Thomas, who struggled all his life with mental illness and alcoholism:

“Do not go gentle into that good night.

Rage, rage against the dying of the light.”

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