Brent Michael Kious, MD, PhD

Oh Canada! Your New Law Will Provide, Not Prevent, Suicide for Some Psychiatric Patients

,” Mark Komrad, MD, raised concerns about recent legislative changes in Canada (Bill C-7) that will permit euthanasia for individuals who are suffering irremediably and intolerably from severe psychiatric disorders.

 The article implied that these legal changes are wrong because they will fundamentally alter the practice of psychiatry, problematizing the field’s inherent commitment to suicide prevention. The piece noted: “Psychiatrists traditionally have done all they could to prevent suicide. Should they really facilitate it instead?”

We agree on one point: Psychiatrists and other mental health providers should do whatever they can to prevent suicide. Suicide is nearly always tragic, often preventable, and usually involves social, psychological, and other circumstances that, if psychiatrists or others were given the chance, could have been improved. No one wants the field to give up on suicide prevention. We also share a concern that Bill C-7 does not contain any requirement that patients seeking psychiatric euthanasia cannot have refused any evidence-based treatments. It would indeed be tragic if someone received medical aid in dying (MAID) to end the suffering caused by an illness that was eminently treatable.

Still, there is much that is problematic about the analysis of this issue. Much of the case against Bill C-7 reverts to old, unpersuasive worries about slippery slopes. While it is true that the scope of MAID in Belgium and the Netherlands has expanded over time, and also true that there has been somewhat more uptake of euthanasia in these countries, it is question-begging to suggest that this shows the original practices were wrong. Furthermore, it is deeply contentious whether euthanasia for patients who regard themselves as having had a complete life, or who find that they are tired of living, is itself 

 Appeals to slippery slopes frequently amount to little more than alarmism, and they are often simply selective reasoning. What should we make of the fact that no slippery slope has been evident in places like Oregon and Washington, where physician-aided dying has been legal for longer than anywhere else?

The article also revisits oft-repeated arguments about the impact of MAID laws on vulnerable groups, especially individuals with disabilities. We concede that these concerns highlight the importance of protections for patients in those groups. Societies like Canada that permit MAID for different groups should strenuously ensure that doing so does not ultimately attenuate those groups’ access to medical or psychiatric treatment, and we underscore the importance of monitoring whether Bill C-7 or other similar legislation leads to adverse effects for persons with disabilities. We also note, however, that thus far there is no compelling evidence that aid-in-dying legislation in any country is causally associated with worsened treatment of patients with disabilities, or with a disproportionate impact on vulnerable groups.

The article cited others who share these concerns, including the First Peoples of Canada, the Canadian Conference of Catholic Bishops, and a UN special rapporteur. It is unclear, however, what we should make of this chorus of objections. As their letter makes clear, the concern of the First Peoples was that MAID generally does not comport with their values, so that their tribal organizations should not be forced to provide or facilitate its provision. That is not exactly the same as an objection to the law itself. The view of the Bishops is unsurprising, and anyway not specific to the expansion of MAID to individuals with psychiatric illness, since that organization is opposed to MAID in any form. Similarly, we have doubts about how much weight we should give to the commentary from the UN special rapporteur: It was not long ago that the UN released a similar 

condemning involuntary electroconvulsive therapy—a treatment that is essential for the management of disabling and life-threatening depression, albeit in rare cases—as a form of torture.

Our primary concern with the article, however, is that it elides important distinctions between the deaths that are usually called 

 and the deaths that are usually permitted under MAID laws in Europe and Canada. Certainly, they all involve an individual hastening their own death by some means—they are all instances, ultimately, of self-killing. But that is where the similarities end. Whether one ultimately agrees with the practice or not, and not withstanding Kim’s 

that many individuals who receive MAID for psychiatric indications in the Netherlands had refused some treatments, one still has to concede that patients who pursue MAID for psychiatric reasons in places like the Netherlands have—unlike the vast majority of individuals who die of suicide—sought prolonged, intensive treatment, been extensively evaluated by psychiatrists and other medical providers, made a considered choice, acted deliberatively and conscientiously rather than impulsively, and been deemed to have an irremediable condition.

It is mistaken, or at least deeply misleading, to frame the central question about Bill C-7 and related laws as “should psychiatry give up trying to prevent suicide and instead start facilitating it?” The important questions—seldom addressed directly by critics of MAID—are whether patients with psychiatric illness could ever be so intractably ill that MAID is a reasonable option, whether it is possible reliably to determine that they are so, and how much treatment they ought to have had before their conditions can really be judged irremediable. We will not hazard an answer to those questions, but we believe they are the ones our field should ask.

is an assistant professor of psychiatry at the Huntsman Mental Health Institute at the University of Utah and a Greenwall Foundation Faculty Scholar in bioethics. 

 is Distinguished Professor of Philosophy and Medical Ethics at the University of Utah. She has authored, co-authored, edited, or co-edited some twenty books, including two collections on end-of-life issues, 

The Ethics of Suicide: Historical Sources

is professor of psychiatry at the Mayo Clinic

 is an emeritus professor of psychiatry at Tufts University School of Medicine and an emeritus professor of psychiatry at the University of Massachusetts-Baystate Medical School. He is the author of 

and a Guggenheim fellow in Health & Medicine. 

has been in the private practice of general and forensic psychiatry for over 35 years. Active in the American Psychiatric Association at both national and local levels, she is past president of Washington Psychiatric Society. 

 is Maddie Katz Professor of Palliative Care Research and Education at the UCLA David Geffen School of Medicine, where he is Vice Chair for Clinical Affairs in the Department of Psychiatry. He is Board Certified in Psychiatry and Hospice/Palliative Medicine. 

is a professor of bioethics and psychiatry in the School of Medicine, Case Western Reserve University.

1. Komrad M. Oh, Canada! Your new law will provide, not prevent, suicide for some psychiatric patients. 

2. Holzman TJ. The final act: An ethical analysis of Pia Dijkstra’s euthanasia for a completed life. 

3. Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez. United Nations, General Assembly, Human Rights Council, Twenty-second Session, Agenda Item 3. February 1, 2013. Accessed July 28, 2021. 

4. Kim SY, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. 

Articles

Some patients are intractably and maybe even irredeemably ill. What should be done for them? 

Let’s Ask the Right Questions About Medical Aid in Dying 

It is common for critics of psychiatry to point to the growing prevalence of mental illness as evidence of something wrong. In 2 essays in 

 presents several criticisms of psychiatry with this theme. She notes that over the past several decades, the prevalence of mental illness in the United States has skyrocketed. The rate at which mental illness is diagnosed in children has increased by a factor of 35, 10% of 10-year-old boys have ADHD, and the lifetime prevalence of mental disorders in the United States is currently 46%. She concludes that there must be some nefarious influence at work, and it seems to her that a cabal of pharmaceutical companies is the most likely culprit.

Dr Angell is an influential critic of medicine, and her arguments, like those in the books she reviews, deserve attention.

 Here I respond to an assumption central to her essays and related critiques. I think many of us take statistics like those above as evidence of something awry in psychiatry because we assume mental illness must be uncommon. In fact, however, there is no good reason to do so.

Start with a comparison between psychiatric and medical illnesses. There is clearly no problem with thinking the latter are common. Consider heart disease. Its lifetime prevalence for men older than 

 and in recent decades, its global prevalence has increased.

 This is cause for alarm, but not skepticism. Cancer is also distressingly common, and no one doubts 

that 19% to 23% of people in the United States will die of cancer

 or that cancer will develop in 44% of all men.

Neither of the usual theories of mental illnesses suggests they should be different from non-mental illnesses. If mental illnesses are merely brain problems, high prevalence should be unsurprising: the brain is a fabulously complex organ, and complex organs are likely to break down. If instead mental illness cannot be fully understood without reference to a patient’s subjective experiences, then high prevalence is still expected, since the trauma and stress that predispose to mental illness are highly prevalent. What, then, occasions our doubt?

There are probably a number of interrelated considerations. First, we may tend to think of mental illness in terms of archetypes such as schizophrenia. Schizophrenia is a chronic and debilitating illness.

 It is also relatively uncommon, with a lifetime prevalence of 0.5%.

 If one supposed all mental illnesses were like schizophrenia-lifelong pathological states undermining a person’s very identity-then it 

 be surprising if someone said that mental illnesses are common: most of us are doing okay, most of the time.

Of course, there is no reason to assume all mental illness is akin to schizophrenia. One could be mentally ill both briefly and mildly, without thoroughgoing upheaval of one’s life. We accept the existence of medical illnesses such as the common cold. Perhaps we should expect they have mental analogues, and that the latter can be common.

The skeptic may worry that expanding our nosology to encompass mental analogues of the common cold would render abnormal what we ought to regard as perfectly normal (ie, acceptable) distress. This concern is superficially compelling, but also confused. Presumably, one problem with classifying “normal” distress as pathological is that it seems to demand treatment. In fact, however, not every medical illness is treated or treatable. The common cold is again an example, but no one thinks it is not a real illness or that it is overdiagnosed.

A related concern might pertain to unnecessary stigma. The label of mental illness entails significant social costs and should not be used without good reason. A diagnosis of ADHD might impair a child’s self-esteem and affect his educational, social, and occupational performance.

 But we should not confuse practical considerations with classificatory ones: how things are, and so how they ought to be classified, is one matter; how we ought to comport ourselves as classifiers is another. Occasionally, someone might be better off not knowing that he or she has cancer or HIV infection. But in neither case does this void the diagnosis.

Skeptics may also share concerns that animated the anti-psychiatry movement of the 1960s and 1970s, which argued that psychiatry relied on dubious normative judgments.

 To be fair, many psychiatric diagnoses probably contain a normative element.

 This should give us pause, since normativity can easily go awry: the norms driving the diagnosis of 

 (a slave’s desire to flee his master) or the DSM’s early inclusion of homosexuality were unquestionably wrong.

 Still, such cases do not show that all psychiatric diagnoses are corrupt, since not all norms are corrupt. Many of the norms implicit in psychiatric diagnoses (such as schizophrenia and other psychotic disorders) are not even 

ones, but rather norms of reasoning and inference. And though some might claim that delusional or paranoid beliefs merely constitute “another way of thinking” as good as any other, we need not take those claims seriously.

To be sure, many diagnoses rely on norms that are moral. We might diagnose major depression in a suicidal person and treat him accordingly, and our diagnosis may be independent of any problems with his reasoning, as distinct from problems with his motivations. How we treat him therefore depends on a judgment about how his life should go, which is surely moral.

But is reliance on moral judgments a problem per se? For this to be true, what we might call 

 would need to be true. Radical pluralism entails that there are no moral requirements extending to behavior that substantially affects only the individual. The anti-psychiatrist thinks many psychiatric diagnoses invoke such requirements, so if radical pluralism is true, such diagnoses are unfounded.

The problem, however, is that radical pluralism is false: moral judgments about others’ self-regarding behavior can be correct. It is easy to say for the sake of argument that we have no grounds for judgments about how others should live, that all such questions are matters of preference. But outside of psychiatry, we make a wide variety of judgments about what others do. As a society, we require persons to refrain from using certain recreational drugs and to do things such as wear their seatbelts. The claim that the underlying judgments are necessarily false is too costly if the only payoff is maintaining a radical critique of psychiatry.

We also make decisions for persons who are unable to make decisions for themselves (eg, young children, adults with dementia). For such “incompetent” persons, the good is not always a matter of preference. But if there are facts about “incompetent” persons’ good, similar facts should hold for competent persons. Competence is a matter of having knowledge, understanding that knowledge, and using the knowledge to reason well.

 If these criteria do not invoke facts about the good, then nothing about competence should make a person more capable of determining his good than the incompetent person. And if the criteria 

 invoke facts about the good, then such facts exist. Either way, radical pluralism is in trouble.

Finally, skeptics may worry that mental illnesses are socially constructed. There are several senses in which this may be true, but none of them clearly suggests mental illnesses are uncommon. One way things can be socially constructed is for their existence to depend on social practices, just as chess games and the Rose Parade are social constructs. Some mental illnesses, such as anorexia nervosa, may be constructed in this fashion. But being the product of social conditions does not make something unreal: the Rose Parade is clearly real, even if it is not natural. Similarly, medical conditions such as mesothelioma, are real, even though they would not occur but for some social practices. Being socially constructed in this sense should not, therefore, impugn the reality of mental illnesses.

Sometimes social construction is a matter of applying arbitrary categories to natural continua. Some think race is socially constructed in this way: variations in skin tone, hair color, and the like are real, but identified races correspond to no natural divisions.

 Our color categories are similarly constructed: color phenomena comprise continuous spectra onto which we impose divisions, which vary somewhat from culture to culture and which are not natural.

 But, again, being non-natural does not entail being unreal: no one would seriously contend that 

is not real, or that we should disband our use of that concept.

Finally, things can be socially constructed insofar as they are what Hacking

 called looping kinds: the phenomena categorized change over time because people’s behavior changes in response to the categories. Mental illness can obviously be like this, but it is again no mark against reality. Most cultural categories loop. The promulgation of the notion of 

in the 1960s probably led more people to become hippies. But no one supposes that hippies were not 

 hippies. The kind looped, but remained real.

To conclude, I should emphasize that I am not trying to argue that mental illness really 

 common, which is partly an empirical matter. Nor am I concerned with defending the legitimacy of the entire corpus of psychiatric diagnoses, many of which could be spurious or overused. My aim instead has been to show that our resistance to the potential ubiquity of mental illness is not a priori justified. Psychiatric illnesses could be just as common as medical illnesses, especially if they can be minor and do not always require treatment. Dr Angell and others may be right to claim that we should be concerned about the current practice of psychiatry. But the simple fact that mental illnesses seem to be common is not one of them.

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http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/?pagination=false

http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/?pagination=false

The Truth About the Drug Companies: How They Deceive Us and What to Do About It.

 Centers for Disease Control and Prevention, National Center for Health Statistics. Respondent-reported lifetime heart disease prevalence among adults 18 years of age and over by sex and age: United States, 1999-2009. 

http://www.cdc.gov/nchs/data/hus/2010/fig03.pdf

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The Myth of Mental Illness: Foundations of a Theory of Personal Conduct.

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 Foddy B, Savulescu J. A liberal account of addiction. 

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 Dr Angell and others may be right to claim that we should be concerned about the current practice of psychiatry. But the simple fact that mental illnesses seem to be common is not one of them.

Brent Michael Kious, MD, PhD

Articles

Let’s Ask the Right Questions About Medical Aid in Dying

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