The Debate

"I have been approached by many psychiatrists who have serious concerns about physician assisted death being applied to mental illnesses."
"Legal definitions are extremely important here. 'Remediable'  could be defined as treatable, or curable. [In psychiatry], complete cures are quite rare. If 'remediable' implies a cure, then almost all psychiatric illnesses could be considered 'irremediable'. [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."
"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."
Dr. Padraic Carr, president, Canadian Psychiatric Association/prof. of psychiatry, University of Alberta

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"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."
"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. We often miss things like depression and delirium and even coercion."
"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."
"I think we need to use some of the same approaches [with requests for doctor-hastened deaths]."
Dr. Romayne Gallagher, expert in palliative care

"This isn't what organized religions, or palliative care doctors or other physicians want."
"Psychiatric illness is simply a disorder of the brain -- it's another part of the body. [If the person is competent], I would see no reason why we should not go ahead and grant their wishes."

Dr. Derryck Smith, professor emeritus, University of British Columbia

UBC psychiatrist Dr. Derryck Smith, a physician adviser to Dying with Dignity Canada, says psychiatric illness is simply a disorder of the brain. If the person is competent, 'I would see no reason why we should not go ahead and grant their wishes.'Photograph by: Les Bazso, PNG , National Post

There are two truisms at work here; one is that nothing is ever simple; the other is that the devil is in the details.

Psychiatrists Canada-wide fear they may soon be expected to give aid to some people who want to hasten the end of their lives. To do so would push an unwilling health professional into the role of "suicide enablers", a designation that most in the profession consider untenable and counter to all the values they hold in their profession.

When the Supreme Court of Canada issued its historic ruling striking down the Criminal Code provisions that prohibits doctors from "aiding or abetting" suicide, they did so granting adult Canadians suffering "grievous" and "irremediable" conditions the right to die with a doctor assisting in their deaths, hitherto forbidden by law.

What complicates matters for psychiatrists is that "cures" are dreadfully infrequent. They are concerned that people who are severely depressed and those with other mental illnesses seeking treatment to enable them to continue living as best they can, will see the new law as an opportunity to seek assisted suicide, perhaps euthanasia -- death by lethal injection. They must be considered mentally competent, capable of providing free and informed consent.

In a suicidal depression, a state that can be alleviated with professional intervention, how mentally competent might an individual be considered to be? Ethicists argue that competent people who struggle with severe depression or other life-compromising mental disorders should be regarded no differently than those competent individuals suffering from incurable physical maladies.

According to Dr. Carr, some psychiatrists view any role in assisting suicide or euthanasia totally counter to their values and want no part of it. At the same time, others within the profession recommend mandatory psychiatrist assessments be undertaken for each individual who seeks an assisted death; in other words psychiatrists could present, under this type of scenario as the ultimate decider.

The polarized view is that to insist that everyone exercising their legal right to a doctor-assisted death undergo a psychiatric evaluation is unneeded and intrusive. Several prominent American psychiatrists wrote in The Hastings Report produced in 2012 that the consulting psychiatrist could be turned "into a secular priest dressed in the clothes of a medical expert". In any event, it could result in a burden to stricken the conscience of the unwilling.

In the opinion of one psychiatrist who spoke at the Canadian Medical Association's recent annual general council meeting in Halifax, many of the patients in her maximum-security hospital are "competent adults. Their conditions are grievous and irremediable, and they do cause enduring suffering. Some of my patients contemplate suicide as means of escape."

Is the issue one of patient autonomy, or the presumption that what the patient wishes for themselves at any given time in their trajectory toward death by natural causes in due time, should override all other considerations, including decision-making at a time of vulnerability that might later be regretted? If palliative care done with great sensitivity and skill can ameliorate the pain and suffering is that not a more agreeable alternative to ending it all?

Perhaps it's an issue of leaving an avenue of escape from the intolerable open to those who see its use. As long as the issue doesn't become one of routine and inclusiveness where neither should become commonplace.