From involuntary incarceration to Medically Assisted Suicide: Mental illness, suicide and autonomous judgement

Abstract

Involuntary commitment of the mentally ill and forced treatment of suicidal persons are practiced worldwide, with underlying premises that contrast with the respect for autonomy upon which Medically Assisted Death (MAD) (euthanasia and assisted suicide) for the mentally ill is based. We trace the transition from paternalistic mass incarcerations to hospitalization only for dangerousness. In response to criticisms that predicting dangerousness is indefensibly inexact, criteria have shifted to emphasize incompetence. Outside the judicial and legislative realms, helplines use different ethical premises operationalized in contrasting practices in response to persons who have attempted or are at imminent risk of attempting suicide. Some respect refusals of help while others organize invasive rescues. In carceral institutions with inhumane conditions, controversial forced feeding protocols pit the desire to save lives against forced living with extreme suffering. As MAD for persons suffering from a mental disorder is increasingly debated, arguments in favor focus on recognition of the capacity for self-determination, the benevolence of ending interminable suffering, and MAD as a human right which the mentally ill should be able to access without discrimination. Opponents cite research on the unpredictable course of mental disorders and inability to predict when the disorder is irremediable. They emphasize pervasive ambivalence in suicidal desires and that legalizing MAD for mental illness is inherently stigmatizing. MAD for mental illness places physicians who are often not familiar with the patient's lifetime social-emotional history in the role of making life-ending decisions. Autonomy must be tempered by protection of vulnerable populations.