Door open for severely depressed: bioethicist
Five years ago, surgeons placed a heavy metal crown over Bruce Ross’s head, fixed his skull into the frame with screws and then bolted it to an operating room table.
In an experimental procedure called deep brain stimulation, they implanted two thin electrodes into the white matter on each side of his brain. When stimulated, the devices did what 21 different drugs, “shock” therapy and years of psychotherapy had failed so miserably to accomplish: “It has taken the negative thoughts away.”
The 55-year-old father and credit union executive no longer has thoughts of killing himself. He sleeps better and has a better appetite. He feels more relaxed and upbeat than he has ever felt since depression first engulfed him when he was in his teens.
Now, however, there may be another, darker alternative for those suffering from severe, intractable depression. Though largely overlooked in the debate sparked by last Friday’s Supreme Court of Canada ruling legalizing doctor-assisted death, the decision applies to more than just patients with incurable physical illnesses.
People with treatment-resistant depression — a crippling form of the disease that actor Robin Williams was said to have battled before killing himself last August — fulfil the criteria for assisted-suicide set out by the high court, argues Udo Schuklenk, a leading Canadian bioethicist.
Ross said he would not have opted for doctor-assisted dying if it had been available to him, but would never begrudge it to others with his condition.
“If we’re going to allow doctor-assisted suicide for other types of intolerable pain, then I would support depression as being included in that category.”
The notion that mental illness might make someone eligible for state-sanctioned assisted death, however, is causing unease elsewhere.
The idea has long been forbidden ground in the assisted suicide debate in Canada. While polls show mounting support for mercy killing of those dying of widespread cancer or “catastrophic” physical illnesses, the public is far more nervous when it comes to mental disorders such as depression. How could the mentally ill be competent enough to provide free and informed consent? Would their thinking not be clouded by the very fact they are depressed?
Depression and other psychiatric illnesses can influence insight and judgment, says Dr. Padraic Carr, president of the Canadian Psychiatric Association. “They can affect the ability to appreciate the situation and manipulate information rationally,” says Carr, who is also a professor of psychiatry at the University of Alberta.
But Schuklenk argues depression alone does not automatically make people incapable of making decisions about their life.
In his analysis, the high court ruling opens the door to putting assisted suicide within reach of competent adults suffering debilitating and “torturous” treatmentresistant depression.
In its historic and unanimous decision, the Supreme Court justices ruled competent, consenting adults suffering a “grievous and irremediable” medical condition causing intolerable physical or psychological suffering have a constitutional right to a doctor’s aid in dying.
Schuklenk said the paralyzing distress of treatmentresistant depression should be given as equal weight as suffering cause by a physical illness.
Depression itself is not terminal. “A patient suffering from treatment-resistant major depressive disorder can live — however miserably — to old age,” he says.
The ethical question is, once the right to assisted suicide is granted to competent adults suffering incurable physical illnesses, how could legislatures or provincial colleges of physicians that will ultimately write the rules for medical aid in dying discriminate against competent, mentally ill adults who have decided life is no longer worth living?
“We know that a large number of these people, at one point or another, commit suicide and it often happens in terrible circumstances,” says Schuklenk, who headed the Royal Society of Canada’s 2011 expert panel on end-of-life decision-making.
“This (physician aid in dying) is a better way for them to end their lives, once you have confirmed competence and you have established that the condition cannot be improved — that these people have undergone years and years of clinical care involving drugs, involving psychotherapy and literally anything you can think of.
“Once those conditions are met and once it is clear that, based on clinical knowledge at the time when the decision has to be made, the condition is not going to improve and they make that call, then I think we should respect that.”
An international leader in mood and anxiety disorders says Schuklenk, a Queen’s University professor in Kingston, Ont., is misguided.
Dr. Sidney Kennedy says severe depression is not like late-stage pancreatic cancer, for which no known treatments available today will ultimately stop the “downward spiral to death.”
“Our field (of psychiatry) is moving forward and I would not want to be in the position of saying, ‘if we hadn’t assisted death and dying in this person five years ago, they could have had a particular treatment that we now see works,’” said Kennedy, a professor of psychiatry at the University of Toronto who is part of the team testing deep-brain stimulation.
Overall, about 11 per cent of Canadians will meet criteria for major depression at some point in their lives. Onequarter will suffer treatmentresistant depression, defined as depression that has not responded to adequate doses and durations of at least two different antidepressants from different classes.
Between 40 and 60 per cent of them, based on published research, will eventually fail all known treatments, Schuklenk says.
Hard-to-treat depression is a harrowing form of existential suffering “that makes the very daily existence and basic things like getting up, getting out of bed and focusing on work torturous,” Schuklenk says.
Up to 15 per cent are at risk of death by suicide.
Kennedy, who holds the Arthur Summer-Rotenberg chair in suicide studies, has had women tell him their treatment-resistant depression was worse than having breast cancer. “There are people who say it is the biggest burden they’ve ever experienced,” he says.
Often the depression is accompanied by severe and crippling anxiety, a combination that can be lethal.
In the Netherlands and Belgium, some clinically depressed people are eligible for doctor-assisted death. In 2013, 42 psychiatric patients died by lethal injection in Holland, more than triple the 12 cases reported in 2012. In addition to depression, the patients suffered from anxiety, phobias and personality disorders. Of the 42 cases, the Dutch Euthanasia Review Committee investigated 32 in 2013. All were judged to comply with the law, Schuklenk says.
The Dutch have in place safeguards to ensure clinically depressed people seeking euthanasia are competent when they make the decision “and that they’ve tried everything for years and it hasn’t worked for them,” Schuklenk says.
He said it would be unreasonable in Canada to deny patients with prolonged, intractable depression medical aid in dying “based on a hunch that a successful treatment might come around soon.”
However, Carr, of the Canadian Psychiatric Association, questions whether treatment-resistant depression would meet the Supreme Court test for “irremediable” suffering.
“There are almost always treatments for most psychiatric conditions,” he says. “Just because you’ve been labelled with treatmentresistant depression doesn’t mean further treatments won’t work.”
Schuklenk argues standard therapies available now fail a significant proportion of patients and because their illness isn’t terminal, “they do not have a ‘natural way’ out of their suffering.”
“The vast majority of these patients are perfectly competent. And whether their life is so bad that it causes enduring suffering that is intolerable to them is for them to decide, not anyone else.”
“JUST BECAUSE YOU’VE BEEN LABELLED WITH TREATMENTRESISTANT DEPRESSION DOESN’T MEAN
FURTHER TREATMENTS WON’T WORK.”
DR. PADRAIC CARR