Medically Assisted Death in Patients With a Mental Illness

Three recent articles in the British Journal of Psychiatry^1-3 discuss whether the criteria for medical assistance in dying for physical diseases (MAiD-PD) should differ from those for medical assistance in dying for mental illnesses (MAiD-MI). The authors note the considerable complexities involved and conclude that we need more study without making a recommendation one way or the other. While I can think of a no more complicated topic, I propose that we can make a recommendation by considering medicine’s theoretical base.

Auguar: Mania and Melancholia

Source: CC-BY-4.0; Self-published work

The topic is timely because MAiD-MI is under consideration in Canada, and several European countries have implemented it. In the U.S., the states that have approved MAiD-PD have not approved MAiD-MI.

The authors make clear that assisted death itself is controversial; for example, some advocate widescale application based on patient autonomy and the right to choose. Alternatively, others cite the sanctity of life and the possible “slippery slope” that can occur after implementation. Certainly, challenges to both sides exist and deserve respect.

Nor do the authors leave any question that, if decided upon, medically assisted death of any type is quite complicated. For example, how does one access it, what should be the training and quality of providers, what are the protective and risky behaviors associated with the intervention, what skills and attitudes must the many professionals involved and patients requesting assisted death exhibit, how important is the impact of such an intervention on providers and families as well as other members of the system, and how do we adapt the intervention for different health care systems?

But, once a group grapples with the complexities and accepts assisted death for those suffering unbearably from an illness, this does not answer if they will include MAiD-MI. Some restrict the intervention to MAiD-PD, while others do not. The exclusive basis for differentiating the two is the presence or absence of a physical disease.

https://www.myupchar.com/en: A Person Suffering from Liver Disease

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Some view suffering from a physical disease as quite different from the disease itself. One has the disease and then suffers. Under our ICD-10 and other classification systems, disease is well-defined with clear-cut criteria, often including radiographic or even microscopic proof. That is, we have a well-established basis for a disease that causes the suffering.

• On the other hand, many see suffering from mental disorders as part of the illness itself because clinicians cannot find a disease to otherwise explain it; see my recent post on this pitfall for psychiatry. We also know much less about the prognosis. The absence of a physical disease cause creates the following dilemma in evaluating those with extreme suffering from a mental illness for assisted death:
  • One side asserts that the suffering is part of the mental illness itself, and the correct stance, rather than assisted death, is to better treat the mental disorder and cure the distress.
  • The other side avers that suffering from a mental disorder requires the same “death with dignity” afforded those with a physical disease. Indeed, some argue that these patients suffer more than those with a debilitating physical disease because they live longer.

Health care systems and societies that accept medically assisted death must answer this question: Do we relieve all suffering vs. just disease-based suffering?

Considering the question from a theoretical standpoint—something lacking in most discussions—can guide us to resolution of the question, in my opinion. A brief background on medical theory helps understand the issue.⁴ Until the 16^th century, the Catholic Church governed medicine with an iron hand and determined its practices. But the 16^th and 17^th centuries Scientific Revolution changed that. Seeking to advance medicine out of its earlier, church-dominated dark ages, increasingly powerful medical scientists (later guided by Descartes and other 17^th century philosophers) confronted the still more powerful Catholic Church. They compromised on this division of labor: the church would govern mankind’s mind (soul, spirit) issues, while medicine and science would care for humans from the neck down. Known now as the “mind-body split,” this beginning of modern scientific medicine saw a massive flowering in the basic sciences of anatomy, chemistry, and physiology—all focused on the physical body and ignoring mind issues. Scientific clinical medicine began in the early 1800s when clinicians first realized that the abnormal organs observed at autopsy represented disease and caused patients’ symptoms. This led to a still greater focus on the physical body—and its diseases. Today, we call the mind-body split the disease-only or biomedical theoretical model. Initially very successful, it guided a doubling of life survival in the 20^th century through medical, surgical, and public health advances that cured or controlled many diseases.

But the model’s isolated focus on disease led to its failure in the late 20^th century because mental illness and chronic diseases became the most common problems clinicians faced. Both disorders require attention to the very psychological and social issues the biomedical model excludes. The alternative theory for medicine is the biopsychosocial (BPS) model. George Engel articulated it in 1977 to integrate the psychological and social features of patients with their diseases. Although given only lip service by medicine, it provides sound guidance because it’s based in a systems view of life, the same holistic approach all other sciences have adopted over the last century; only medicine has failed to embrace a systems view.

I propose that the mind-body split is the core issue in the MAiD-MI debate—is there a physical disease or not? An isolated focus on physical disease sees no role for patients with a mental illness because they have no underlying disease, their suffering aside. Alternatively, from the BPS model vantage point, whether there is a disease or not makes no difference. It’s the totality of the mix of relevant biological (disease), psychological (mental), and social (environmental) factors that determines the patient’s suffering. That is, regardless of its cause, suffering becomes the key determinant rather than the presence or absence of a disease.

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We must, in my opinion, embrace the systems view. Not only is it more scientific (accepted by all sciences other than medicine), but it also is more humane. A BPS perspective, however, does not make the problem simpler. Rather, by encompassing MAiD-MI, it turns attention to the difficulties in diagnosis, treatment, and an often longer life expectancy. We likely will find that even more stringent guidelines apply than with MAiD-PD. To illustrate the greater complexity, here are just a few questions we must decide upon to approve assisted death for those suffering from a mental disorder: the specific treatment and its duration, how many treatment trials qualify (and, perhaps, by how many different therapists), how long must the mental disorder have been present, and who other than the patient, if anyone, must be involved in the decision.

The authors rightly value various medical stakeholders’ input in deciding whether (and for whom) to embrace assisted death. But I believe they could better emphasize the role of society, the importance of which social theorist Hannah Arendt has made so clear.⁵ Before we make a decision, the public of the state or country involved must thoroughly debate these issues and, then, weigh in with its decision, likely taking months if not years. The decision is not medicine's to make. The public has the last word when science debates which direction to take on a contentious issue.