In 2016, after the Supreme Court ruled that a prohibition on medically assisted dying is unconstitutional, the federal government passed legislation that permits assisted dying for patients under certain conditions. Individuals may receive medical assistance in dying if they have a grievous and irremediable medical condition that involves unbearable suffering, and when their natural death is reasonably foreseeable. While the law allows people with mental illness to qualify for assisted death if they also have a physical condition that meets the criteria, individuals whose sole medical condition is mental illness are not eligible. So long as broader societal risks can be managed, extending assisted dying to people with mental illness is a more compassionate and just path for society to pursue.
Misperceptions about mental illness lead some people to oppose extending the right to medically assisted death to people with mental illness. Many believe that psychological suffering is less onerous than physical suffering. Others maintain that mental illness impairs the rational, careful thinking required to provide informed consent. And because mental illnesses are rarely associated with imminent natural deaths, providing medical assistance in dying seems premature, and perhaps even heartless, to many. These impressions offer poor guidance in the debate.
McGill University philosopher Daniel Weinstock and others have noted that the moral case for medically assisted dying rests on two principles—respect for individual autonomy and compassion. By allowing individuals to choose the time and manner of their deaths, just as we allow people to choose how they will lead their lives, we respect a principle with a long pedigree in liberal societies. We might prefer that individuals not end their lives prematurely, but we violate their autonomy if we prevent them from doing so. It is not clear why this principle should apply any less to people with mental illness than it does to people with physical illness.
Moreover, a principle of compassion holds that where there is suffering in society, we ought to do what we can to alleviate it. But where suffering is unavoidable, unnecessary and unbearable, offering medical assistance in dying is the compassionate course of action. In its decision in Carter v. Canada, the Supreme Court highlighted what Alheli Picazo rightfully calls a “callous dilemma.” Individuals who are “grievously and irremediably ill,” and who lack medical assistance in dying, “may be condemned to a life of severe and intolerable suffering. A person facing this prospect has two options: she can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.”
A compassionate society will provide an alternative that dissolves the dilemma and avoids cruelty. There is no reason why compassion, like autonomy, should apply less to those with mental illness than it does to others.
So why do we hesitate to extend assisted dying to those whose sole medical condition is mental illness? It may be that widespread negative stereotypes about people with mental illnesses lead us to think that they are irrational and ill-equipped to choose wisely the timing and manner of their deaths. Yet, the law already requires a demonstration of informed consent whether one has a mental illness or not. In that case, excluding people with mental illness from assisted dying adds a barrier with no rational purpose.
Some have argued that extending assisted dying to those with mental illness de-stigmatizes and normalizes suicide in society more broadly and that this could lead to an increase in suicide among people who would not qualify for assisted dying. There is limited, but disputed evidence that suicide rates remain the same or increase (where we would expect them to decline) in jurisdictions that introduce assisted dying.
At the same time, a society that allows assisted dying creates opportunities for individuals considering suicide and seeking assistance to learn about alternate treatments and options that could reduce their suffering and keep them alive. A key question, then, is whether a society with medically assisted dying will see an increase in suicide due to normalization, or a decrease as more people receive life-saving treatment when they engage with medical professionals. The Council of Canadian Academies’ expert panel on assisted dying for people with mental illness should address this critical question in its report to the Minister of Health due in December 2018.
Acknowledging these important and still unsettled empirical issues, an ethically informed discussion of assisted dying for those with mental illness points to the conclusion that it ought to be extended. That conclusion will make some people uncomfortable, which is understandable. Death does not merely end a person’s suffering; it ends a person’s very existence. Still, while assisted death is a tragic alternative, it is nevertheless a compassionate alternative to a callous dilemma.