is professor of psychiatry at the Mayo Clinic.

J. Michael Bostwick, MD

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 

Suicidal Behaviors and Ideation in Oncology Patients

” by Carey J. Myers, MD, PhD, and Carolina Retamaro, MD

We understand that the authors focused on assessments for psychopathology and suicide risk in patients undergoing disease-directed cancer treatments. In the section “Is Refusal of Treatment a Form of Suicide?” they touch on the concept that (consistent with long-held personal health values and in the absence of contributing psychiatric illness) some patients may choose to refuse—or start and eventually discontinue—disease-modifying therapies with the aim of letting their disease take its natural course, even though that might hasten death. What they do not explore are more active forms of hastening death.

We wish to address this omission. Ten states and the District of Columbia, representing roughly 22% of the United States population, have now legalized Medical Aid in Dying (MAID). While Myers and Retamaro do not directly raise the relationship between cancer suicides and MAID, we believe it important enough to pen a response.

Data from MAID-permitting states shows that patients whose advanced malignancies are likely to lead to their deaths within 6 months comprise the vast majority of those pursuing MAID: 70% to 80% of MAID deaths 

 Broadly, MAID laws allow terminally ill adults with decision making capacity to request and receive from a willing prescriber a lethal prescription to self-administer at the time of their choosing. All current state laws explicitly stipulate that such deaths are not suicide. The District of Columbia statute, for example, asserts that, “actions taken in accordance with this act do not constitute suicide, assisted suicide, mercy killing, or homicide.”

 Maine’s statute adds that state reports may not refer to acts committed under this Act as 

 and Washington State’s statute instructs that “state reports shall refer to practice under this chapter as obtaining and self-administering life-ending medication.”

 Such stipulations guide how to understand the practice, how to complete death certificates, and how to prevent insurers from refusing to pay death benefits. Most importantly, they are intended by lawmakers to help avoid the stigma of suicide.

A large and growing literature outlines the differences between decisions to decline disease-modifying treatments (or directly hasten one’s own death) and the psychopathology associated with suicidal behavior.

 The latter may trigger efforts at suicide prevention and intervention, sometimes even against an individual’s will.

 And while cases with characteristics of both conventional suicides and MAID do occur, clinicians must be prepared to distinguish between them in order to 

This does not challenge the undeniable fact that some cancer patients die by (conventional) suicide. We simply argue that MAID is not the same as those deaths.

We recommend that professionals in jurisdictions with MAID familiarize themselves with relevant statutes, and that terminally ill oncology patients receive accurate information about their rights under the law. Together with accurate predictions about prognosis and expected outcomes of available treatments, this information is essential for physicians who want to work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.

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 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

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

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

 She has been named one of the “Mothers of Bioethics.” 

 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. 

1. Oregon Health Authority. Oregon death with dignity act. February 26, 2021. Accessed June 10, 2021. 

2. California Department of Public Health. California end of life option act 2019 data report. July 2020. Accessed June 10, 2021. 

3. Washington State Department of Health. 2018 death with dignity act report. July 2019. Accessed June 10, 2021. 

4. District of Columbia Law 21-182(16). Death with Dignity Act of 2016.

5. LD 1313(HP 948). An Act to Enact the Maine Death with Dignity Act.

6. 70.245.180(1). The Washington Death with Dignity Act.

7. Puts MT, Tapscott B, Fitch M, et al. A systematic review of factors influencing older adults' decision to accept or decline cancer treatment. 

8. Strouse TB. Requests for PAD and the assessment of capacity. 

9. Cohen LM, Steinberg MD, Hails KC, et al. Psychiatric evaluation of death-hastening requests. Lessons from dialysis discontinuation. 

10. Yager J, Ganzini L, Nguyen DH, Rapp EK. Working with decisionally capable patients who are determined to end their own lives. 

11. Bostwick JM, Cohen LM. Differentiating suicide from life-ending acts and end-of-life decisions: a model based on chronic kidney disease and dialysis. 

12. Creighton C, Cerel J, Battin M. Statement of the American Association of Suicidology: “Suicide” is not the same as “Physician Aid in Dying.” American Association of Suicidology. October 30, 2017. Accessed March 30, 2021. 

Patients with terminal illnesses may choose to refuse treatment or even hasten their own deaths, but is that the same thing as suicide?

J. Michael Bostwick, MD

Articles

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

A New Question in End-of-Life Ethics