“Palliative Psychiatry” and Assisted Suicide: Compassion? Abandonment? Or Something Far Worse?

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COMMENTARY

The concept of “palliative psychiatry,” “terminal psychiatric illness,” or “end stage psychiatric disorder” has been floated by advocates as a compassionate way to address enduring suffering of individuals facing chronic mental illness.¹ As a consultation-liaison psychiatrist with expertise in psycho-oncology, to me it is clear that the stated aim of prioritizing quality of life should be shared by all high quality psychiatric care, and certainly is not the monopoly of palliative psychiatry. The real issue is that palliative psychiatry takes a dangerous turn when discussions invariably lead to advocacy for assisted suicide policies for mental illness, which reflect neither palliative medicine, nor psychiatric care.

(A note on terminology: Although Canada coined the term medical assistance in dying or MAiD in 2016, this author believes the term is a misnomer when providing death to individuals who are not otherwise in the process of dying. Instead, this paper will use the term physician-assisted death [PAD].)

Those in favor of PAD for mental illness cite the fact that some individuals die from their mental illness and propose that those with end stage psychiatric disorder should be able to apply for PAD. This rationale naively ignores the obvious distinction between whether some individuals die (we all die, life is a terminal condition) vs the real point of whether we can predict which individuals will not get better. Advocates propose making such predictions based on review of the patient’s historical course, but worldwide evidence shows that we remain unable to predict which individuals will recover, and which will have an irremediable mental illness.² Even precision modeling of treatment-resistant depression suggests such attempted predictions are wrong over half the time.³

By ignoring this issue, while couching it as offering compassionate escape from unresolvable suffering, PAD providers would actually be providing death under false pretenses to many individuals who would have improved. In essence, the white lab coat will have colluded with the patient’s symptoms of despair in telling the patient (incorrectly most of the time) that they will never get better. PAD expansion advocates claim patient autonomy and competence are undermined if patients are not able to choose PAD for mental illness, but the reality is much starker—despite some believing otherwise, it is we as clinicians who are not competent to determine irremediability of mental illness, which is the fundamental premise of all PAD laws. Bypassing this core safeguard with unscientific and false predictions of irremediability, with individual practitioners conferring a medical credibility that does not exist, renders other potential safeguards meaningless.

Concerningly in this debate, expansion advocates frequently mischaracterize that cautions against PAD for mental illness “have been based on religious, historical, and cultural arguments.”¹ This belittles the evidence-based cautions that have been raised and dismisses widespread evidence demonstrating that expanding PAD beyond end-of-life conditions risks marginalized populations. Advocates cite data showing that privileged populations access PAD for end-of-life conditions to support arguments to expand PAD to mental illness, yet ignore the inconvenient truth that, unlike end-of-life PAD, psychiatric euthanasia is associated with unresolved social suffering and a 2:1 gender gap of twice as many women as men being provided death for their mental illness⁴ (which parallels the 2:1 ratio of women to men who attempt suicide when mentally ill, most of whom do not die by suicide and do not try again). Rather than being concerned about this gender gap, despite Canada not even requiring past access to treatment before providing PAD, the activists charged with establishing Canadian safeguards for psychiatric euthanasia concluded death by PAD could be provided for mental illness “without adding new legislative safeguards.”⁵ The chair of the same federal panel openly stated the gender gap of twice as many women getting psychiatric euthanasia “does not concern” her since she doesn’t think “anybody knows what it means.”⁶ Advocates similarly ignore evidence showing overlapping characteristics of traditionally suicidal populations, who may benefit from suicide prevention, with those receiving PAD for mental illness.⁷ Instead, similar to providing false reassurances of being able to predict irremediability, advocates make evidence-free claims they can separate suicidality from other motivations for psychiatric PAD requests. Essentially PAD assessors are taught it is “suicidality” if the patient is impulsive and acting on their own, but a different (and acceptable) motivation for PAD if they are instead coming to the assessor for a nonimpulsive PAD request.⁸ These so-called distinctions are based on a fallacy, evidence shows most suicides in North America are nonimpulsive.⁷

This raises the question of what our role as a profession is. At a recent American Psychiatric Association (APA) symposium on assisted dying hosted by the Council on Psychiatry and Law on September 23, panelists suggested it is not our role to set policy, but to follow shifting public views towards more expansive PAD policies. This bypasses a key role we, as medical experts, are charged with, which is ensuring that public views and policy are informed by medical evidence. Canada, which now provides more PAD than any other country and has seen the sharpest rise of PAD rates on the planet, is set to further expand PAD to mental illness by 2027, and our profession abdicated that role. A former Ontario Medical Association President has described our PAD processes as having fallen victim to regulatory capture, whereby a small but influential group of nonrepresentative individuals drives the policy process.⁹

As a past president of the Canadian Psychiatric Association (CPA), I have seen this in my own former association. During the consultations leading to Bill C-7 and the sunset clause, which is what led to Canada’s decision to expand PAD to mental illness, in all its written and oral submissions and input, CPA leadership never once mentioned suicide risks associated with mental illness or marginalization, nor spoke to the importance of suicide prevention.¹⁰ Indeed, the CPA never used the words “suicide,” “suicidal,” or any variant in any of these consultations on death seeking and mental illness. Imagine a respirologist association refusing to mention smoking as a risk factor for lung disease in public consultations on lung health. While feigning official “neutrality,” CPA leadership was publicly acknowledged as supporting psychiatric euthanasia by repeatedly claiming it would be discriminatory not to offer PAD for mental illness,^11,12 this despite offering no evidence on how or whether irremediability could be predicted. And while making legalistic claims about discrimination, it openly declined offering medical evidence—when asked in Senate hearings whether the CPA agreed with other experts that more research was needed prior to providing PAD for mental illness, the CPA President replied “I guess that is a legislative decision.”¹³

Abdicating responsibility for providing evidence-based medical expertise regarding irremediability and suicidality, while uncritically facilitating expansion of PAD policies, represents a profound failure in Canada. Now we are seeing such blind spots emerge in US discussions as well. At the aforementioned APA Psychiatry and Law symposium, which was billed as discussing “Canadian challenges,” no panelist presented details of concerning data already emerging, even before Canada’s planned expansion of PAD to mental illness, that demonstrate some of our most vulnerable Canadians are being provided death for reasons associated with traditional suicidality. Of the over 13,000 Canadians euthanized by PAD in 2022, over one third cited feeling a burden and nearly one fifth cited loneliness as sources of suffering fueling their PAD requests.¹⁴ On the recently introduced “Track 2,” that allows PAD for nonterminal conditions to adults with any disability, including for nebulous conditions of frailty and hearing loss, gender gaps are emerging of a disproportionate number of women receiving PAD.¹⁴ And the Ontario Chief Coroner, representing Canada’s most populous province, recently concluded that “individuals whose deaths were Track 2 (nonterminal) were much more likely to live in neighbourhoods with higher levels of residential instability, higher material deprivation, and greater dependency than those in Track 1 (end-of-life).”¹⁵ Yet none of this critical evidence entered the panelists’ discussions, which focussed instead on whether psychiatry should label some patients as having “terminal” psychiatric conditions to qualify these otherwise nondying individuals for PAD (which, as stated previously, would be based on nonscientific assessments wrongly predicting irremediability).

In Canada, again even before PAD expansion to mental illness, we are seeing individuals receiving PAD driven not by illness suffering, but by social suffering including poverty, housing insecurity, isolation, and lack of access to care.¹⁶ This does not mean that everyone getting PAD in these situations is driven by social suffering, but are we to ignore that these PAD expansions risk the marginalized seeking PAD not to avoid a painful death but to escape a painful life? The privileged perspective of some advocates does precisely that. Despite individuals who died by PAD themselves articulating that “it was not a disease that took me out, it was a system,”¹⁷ well-funded advocacy groups like Dying With Dignity¹⁸ boldly maintain that it is a “myth” that “vulnerable populations can be eligible (for PAD) if they are suffering from inadequate social supports, including housing”¹⁹ as they lobby those in power who have shaped PAD policies.²⁰ Meanwhile, those in power rarely mention the cost savings of “death with dignity” compared with costly medical and social supports required for a life with dignity for those with disabilities.

In this context, the failure of the profession to provide crucial evidence, while wrongly reassuring that assessors can predict irremediability and separate suicidality from PAD requests, is even more troubling. This failure entrenches an illusion falsely medicalizing and legitimizing that PAD is always provided to alleviate unresolvable illness suffering, when in reality the most marginalized are being provided death not to escape illness but to escape social suffering. Scholars are now emphasizing how, rather than being “cloaked as medical care,” assisted suicide is not only outside the field of palliative care, it should be outside the house of medicine.²¹

The United Nations Office of the High Commissioner for Human Rights has recognized the risks of providing assisted suicide to marginalized nondying individuals, entreating that “disability should never be a ground or justification to end someone’s life directly or indirectly,” and concluding that “these assumptions, which are grounded in ableism and associated stereotypes, have been decisively rejected by the Convention on the Rights of Persons with Disabilities. Under no circumstance should the law provide that it could be a well-reasoned decision for a person with a disabling condition who is not dying to terminate their life with the support of the State.”²²

The concept of “terminal psychiatric illness,” as it relates to predicting who will never improve for purposes of qualifying for PAD, may reflect an ideology or a worldview, but it does not reflect evidence. It is not compassionate to collude with a patient’s mental illness symptoms and tell them they will never get better, when evidence shows us our predictions will be wrong over half the time. It is beyond abandonment to provide nondying, marginalized individuals death under false pretenses.

During the COVID-19 pandemic, concerns emerged that social policies jeopardizing marginalized lives were enabling “social murder,”²³ a term coined by Friedrich Engels in the 19th century describing policies leading to working conditions causing the premature deaths of workers that Engels felt those in power were responsible for. As I point out in a recent BMJ rapid response, “what more fitting term [than social murder] could there be to describe policies actively providing death to non-dying marginalized individuals, who seek readily available state facilitated suicide since society failed to offer opportunities to relieve social suffering?”²⁴

Whatever our personal worldviews, the integrity of our profession demands that we ensure relevant evidence guides public policies, especially those literally involving life or death—the cost of complicity otherwise is just too high.

Dr Gaind is a professor and governor at the University of Toronto, Chief of Psychiatry at Sunnybrook Health Sciences Centre, Honorary Member of the World Psychiatric Association and former president (but no longer member) of the Canadian Psychiatric Association. He is not a “conscientious objector” to PAD and previously was physician chair of his former hospital’s assisted dying team. Views expressed are his own and not meant to represent any group he works with.

References

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