Deciding on assisted death in context of mental illness highly complex, experts say

One of the most contentious issues sparked by Canada's upcoming right-to-die legislation is whether people with mental illness should be eligible to seek a doctor's help to end their lives, along with those suffering from a "grievous and irremediable" physical disease like terminal cancer.

• When it comes to physician-assisted death, could religious hospitals ethically refuse?
• Right to die: Should 'mature minors' have access to doctor-assisted death?
• Catholic Archbishop of Toronto speaks out against assisted dying

Last week, a parliamentary committee recommended that Canadians with psychiatric disorders that cause intolerable suffering should be included in any regulations governing physician-assisted death, which becomes legal June 6 under the Supreme Court of Canada's landmark ruling a year ago.

The court made no specific pronouncement about medically assisted dying for those with a psychiatric illness, and that has left mental health experts wondering how its decision might be interpreted — and what that could mean for such a vulnerable segment of the population.

"We know that society would not accept that people should be treated differently just because they have a different illness," said Dr. Sonu Gaind, president of the Canadian Psychiatric Association.

"But the issue that we're really concerned about … is to make sure that there is full understanding of how in any assisted-dying framework, key processes that can be affected by mental illness are properly assessed," he said, adding that it should be psychiatrists conducting the required evaluation.

"They're complex issues and we really want to make sure there are proper safeguards and expert assessment when mental illness is present."

Depression vs. sound reasoning

Of major concern is how to tease apart whether a request for aid in dying arises from a person's mental state related to their illness — severe depression, for instance, can lead to suicidality — or sound reasoning based on a desire to escape prolonged suffering.

"Although both lead to the same outcome … the connotations are very different between suicide as we've traditionally talked about it and medically assisted dying," said Gaind.

When people are suicidal, they often can't articulate why they are depressed or want to die, he said, explaining that an inability to take pleasure even in positive aspects of their lives, a sense of worthlessness, and lack of hope for the future are all hallmarks of depression.

Whether a person has the capacity to make such a life-and-death decision — a requirement to be eligible for aid in dying — also needs to be evaluated, given that mental illness can distort thinking and impair the ability to process relevant information and to appreciate consequences of a decision.

"This isn't to suggest just because someone has a mental illness that they lack capacity," said Gaind. "There are many times where people can still have full capacity to make all sorts of decisions, even when they have mental illness."

But that's not always the case: "You can have capacity to make one decision and lack capacity to make a decision about something else," he said.

Lucy Waters, whose 57-year-old son Gary has struggled on and off with schizophrenia affective disorder for the last 30 years, believes most people with mental illness are not capable of making a reasoned decision about assisted death and she's horrified by the prospect they may be included under pending legislation.

"It's scary, really scary … It is just so wrong to even consider it with mental illness," Waters said from Vancouver.

"Early intervention is so important. If people are let go, they become extremely ill and then I suppose would qualify for help to commit suicide. But there's no need of it because if you treat someone quickly, as in any disease, it's very helpful."

Access to treatment difficult

However, people with mental illness can't always access treatment, said Ana Novakovic, policy and government relations co-ordinator for the B.C. Schizophrenia Society.

Indeed, a 2012 report by the Mental Health Commission of Canada found that only one in three adults and one in four children and teens were able to get needed treatment and psychosocial support.

In any given year, one in five Canadians experiences a mental health problem, with a cost to the economy of more than $50 billion, the report states. Of the 4,000 Canadians who die each year from suicide, most have a psychiatric disorder of some kind.

"So part of the concern here is that people might be looking to assisted dying, not because they have an illness that can't be treated or supported, but because they can't access those treatments and support," Novakovic said from Vancouver.

Top court guidelines

In its ruling, the Supreme Court said anyone seeking assisted death must be assessed by two independent doctors. For those with mental illness, the Schizophrenia Society wants those two physicians to be psychiatrists trained in the complexities of mental disorders.

Novakovic said the patient's request should be in writing and a panel of witnesses — ideally family members or intimate friends with a long-standing, in-depth knowledge of the person — should provide testimony about the day-to-day effects of their illness.

Doctors making the decision must be familiar with all the nuances of the person's illness and their full treatment history, so they can determine whether it's severe depression or psychosis driving them to seek assisted suicide, she said.

"Or is it that they haven't had adequate treatment and support and they feel like they have no other option?"

The high court also said a patient's condition must be irremediable to qualify for a doctor's help to die. But Gaind stressed the notion of irremediability is vastly different in the context of mental illness, compared with physical disease.

"In mental illness, we're dealing not just with symptoms of the psychiatric condition. We also know that suffering is often worsened by psychosocial factors, things like inadequate housing, social isolation, poverty and lack of employment."

'Very different concepts'

Addressing those factors, along with medications and other therapies, can make a huge difference in mediating the severity of mental illness, he said.

Having treatment-resistant illness — when a person doesn't respond sufficiently to two trials of drugs, for instance — doesn't mean the condition is irremediable.

"They're very different concepts."

Waters said there were times when her son Gary, who had been hospitalized due to schizophrenia several times over the last three decades, "certainly got very low." But she doesn't know how close he came to wanting his life to end.

But thanks to effective medications and services that include supportive housing, "he's really enjoying life now," his mother said. "We dearly love our son and we're so glad that he can come over and be part of our family life again, because he's so much better.

"We've never given up. Never."