A psychiatrist’s duty is to bring meaning, purpose, and hope to patients—not the option of medically assisted suicide.
FROM OUR READERS
I wish to respond to a letter by Kious et al, “Let’s Ask the Right Questions About Medical Aid in Dying.” This letter is a rejoinder to an article by Mark Komrad, MD: “Oh, Canada! Your new law will provide, not prevent, suicide for some psychiatric patients.”
The letter objects to slippery slope arguments, saying that allowing medical aid in dying (MAID) will not lead to abuses. In response it must be said that there are already unequivocally widespread abuses in the Benelux countries (euthanasia without consent, euthanasia without standard treatments tried first, euthanasia with psychiatrists’ objections on eligibility being overruled/ignored, doctor shopping to get the desired outcome) and these abuses could not have occurred without the original practices being allowed, paving the way.1-5 The slippery slope is indisputably real, and the reality is that given an inch, proponents of MAID in those nations took a mile. If the original practices lacked safeguards that could effectively prevent these abuses, then they were wrong by virtue of an inadequacy that allowed for, or even fostered, judicial, clinical, and practical abuses.
The letter claims that, “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 wrong.” This statement completely undermines the claim that slippery slopes are not a concern. Once assisted suicide is allowed for some, it will be allowed for others, for increasingly dubious reasons.
The letter also says, “appeals to slippery slopes frequently amount to little more than alarmism … 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?” This is what we should make of it: America has better clinical and legal oversight, and greater fear of legal consequences. Euthanasia has not been normalized as a social value, but once it has been legalized how long will that be the case?
The letter also claims 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.” Is the repeated, passionate testimony from individuals with disabilities who were offered medical suicide before care not compelling? The 7-minute testimony of Gabrielle Peters before the Senate of Canada is particularly poignant and compelling in this regard.6 The stories and experiences of individuals with disabilities are being ignored.
The letter also dismisses the views of the Catholic Bishops: “the view of the (Catholic) 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.” The Catholic moral position on assisted death is underpinned by careful reasoning, deserving at least of consideration, especially when 55% the Canadian population identifies as holding Christian values, and 30% are specifically Catholic.7 More significantly, the legislation has been soundly condemned by leaders of all major faiths.8
The UN Special Rapporteur has strongly condemned the Canadian legislation. The letter says, “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 report 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.” Dismissing a current claim because of an older mistaken claim is patently fallacious. And to be clear, these repeated UN condemnations were supported by over a hundred Canadian disability organizations.
The letter says that although some who received MAID refused other treatments, patients who pursue MAID receive extensive treatment and evaluation by psychiatrists and other medical professionals, who judge them to have an irremediable condition. Those who end their lives through MAID act deliberately, not impulsively. But if these patients are so conscientious and deliberate, then why do they need psychiatrists’ assistance? They could read one of the many suicide manuals available (one of which is written by Dutch doctors9) and painlessly kill themselves. The letter in effect sanitizes and morally exonerates suicide through the medicalization of what is not a medical act.
The letter ends by saying,
“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—the ones that were not recognized—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.”
If you substitute the word suicide for MAID in this sentence what is apparent is that the important questions are really: can rational suicide be morally acceptable? And should psychiatrists do only selective suicide prevention? I believe the answer, to both questions, is no. Either psychiatrists have a unique and sacrosanct duty of care (that inextricably entails the preservation of life) or they do not. Our job as psychiatrists is to help bring meaning, purpose, and hope and to be unfailing in our efforts to do so.
Dr Maher is president of the Ontario Association for ACT & FACT and editor-in-chief of the Journal of Ethics in Mental Health.
1. Kulczyk P. The ECHR is looking into the abuses of euthanasia in Belgium. European Centre For Law & Justice. July 23, 2019. Accessed August 27, 2021.
2. Du Bus C. Euthanasia in Belgium: Analysis of the 2020 Commission Report. European Institute of Bioethics. November 16, 2020. Accessed August 27, 2021.
3. Kim S. How Dutch law got a little too comfortable with euthanasia. The Atlantic. June 8, 2021. Accessed August 27, 2021.
4. Lane C. Children are being euthanized in Belgium. The Washington Post. August 6, 2018. Accessed August 27, 2021.
5. What could help me die? Doctors clash over euthanasia. Associated Press. October 26, 2017. Accessed August 27, 2021.
6. ‘Dehumanizing’: People with disabilities say they’ve been ignored in Bill C-7 assisted dying debate. Press Progress. February 17, 2021. Accessed August 27, 2021.
7. Lipka M. 5 facts about religion in Canada. Pew Research Center. July 1, 2019. Accessed August 27, 2021.
8. Allan B, Elliott S, Blackaby R, et al. We can and must do much better: religious leaders in Canada oppose Bill C-7 “An Act to amend the Criminal Code” (medical assistance in dying). Accessed August 27, 2021.
9. Sheldon T. Dutch doctors publish guide to "careful suicide". BMJ. 2008;336(7658):1394-1395.