Psychiatrists fear role as ‘suicide enablers’
Mental illness poses dilemma for assisted death
After practising for generations to prevent suicide, psychiatrists across Canada could soon be asked to help some people kill themselves — thrusting the profession into what some of its members are calling the untenable role of “suicide enablers.”
In its historic ruling striking down the Criminal Code provisions prohibiting doctors from “aiding or abetting” suicide, the high court granted adult Canadians suffering a “grievous” and “irremediable” condition the right to die a doctor-hastened death.
The ruling is creating deep discomfort in a field of medicine where “cures” are rare, and where many worry there is every possibility severe depression and other mental illnesses could meet the test for assisted suicide, or even euthanasia — death by lethal injection — as set out by the court, as long as the person is competent and can provide free and informed consent.
“I have been approached by many psychiatrists who have serious concerns about physician assisted death being applied to mental illnesses,” said Dr. Padraic Carr, president of the Canadian Psychiatric Association and a professor of psychiatry at the University of Alberta.
“Legal definitions are extremely important here,” he said. “Remediable” could be defined as treatable, or curable. In psychiatry, he said, “complete cures are quite rare.” Most treatments are directed at relieving symptoms.
“If ‘remediable’ implies a cure, then almost all psychiatric illnesses could be considered ‘irremediable,’ ” he said.
If, on the other hand, “remediable” is defined as treatable, most psychiatric illnesses wouldn’t meet the standard, “because there are almost always treatment options we can try,” Carr said.
“Intolerable” and “enduring” suffering are also problematic, he said. Symptoms of psychiatric illness can wax and wane over time, Carr said. “For weeks or months, a patient could be suicidal, and yet that situation could change.”
“The big fear for psychiatrists is that they may be participating in physician-assisted death, when there is a chance for treatment.”
While Carr believes psychiatric illnesses likely wouldn’t meet the criteria as currently set out by the court, ethicists have argued competent people struggling with severe depression or other mental disorders should be treated no differently than competent people suffering from incurable, physical ones.
Either way, some psychiatrists want no role whatsoever in assisted suicide or euthanasia, Carr said.
Others are calling for mandatory psychiatric assessments for every person seeking an assisted death, meaning psychiatrists could become the ultimate arbiters.
“After working in end-of-life care a long time, you realize that people have ups and downs in their mood, in their feelings, in how they see their future,” said Dr. Romayne Gallagher, a leading expert in palliative care who is among those calling for a psychiatric referral for every request for hastened death.
“Physicians might just take somebody at face value and say, ‘ Oh, OK, I need to honour your autonomy,’ without exploring why they might be thinking this way,” Gallagher said.
“We often miss things like depression and delirium and even coercion,” she said.
“If someone comes to emergency and says, ‘I want to kill myself,’ they’re seen by the psychiatrist, and the psychiatrist will always get collateral information from their families in trying to understand what’s going on,” Gallagher added.
“I think we need to use some of the same approaches” with requests for doctor-hastened deaths, she said.
Others say it ’s unfair to cast psychiatrists in the role of “gatekeepers,” or to force every person exercising his or her legal right to a doctor-assisted death to undergo a mental evaluation. Mandatory assessments, several prominent U.S. psychiatrists wrote in 2012 in The Hastings Report, would turn the consulting psychiatrist “into a secular priest dressed in the clothes of a medical expert.”
One psychiatrist, speaking at the Canadian Medical Association’s recent annual general council meeting in Halifax, said many of the patients in her maximum-security hospital are “competent adults. Their conditions are grievous and irremediable, and they do cause enduring suffering,” she said. “Some of my patients contemplate suicide as a means of escape.”
The Supreme Court ruling, she said, “will, from time to time, put psychiatrists in the untenable position of being suicide enablers,” she said, “at the same time mental health acts require us to protect our patients.”
Others argue the issue is about patient autonomy. “This isn’t about what organized religions, or palliative care doctors or other physicians want,” said Vancouver psychiatrist Dr. Derryck Smith, a professor emeritus at the University of British Columbia and physician advisor to Dying with Dignity Canada.
“Psychiatric illness is simply a disorder of the brain — it’s another part of the body,” he said.
If the person is competent, “I would see no reason why we should not go ahead and grant their wishes,” he said.