Wishing you won’t be here: Medical assistance in dying for psychiatric patients

Abstract

Summary The Canadian Supreme Court's decision in Carter v. Canada conceivably allows depressed psychiatric patients without a terminal physical illness to claim that they meet the criteria for physician-assisted death. Bill C-14, aka the Medical Assistance in Dying Act (MAiD), conceivably does not: patients suffering from mental illness are supposedly not facing an impending death from their disorder that is reasonably foreseeable. Specific concerns have been raised about major depression as hopelessness and suicidal thinking are symptoms. If psychiatric patients are candidates for MAiD, then concerns about incurability, appreciation, and voluntariness could be met by a “conservative” oversight regime that requires extra safeguards and sufficient evidence to offset them. It should require: 1) substantive clinical evidence that treatments have failed, and 2) substantive narrative evidence of how patients evaluate the risk of premature death. As per 1), it is argued that treatment refusal will not by itself determine incurability. An approach for 2) is proposed that uses methods derived from narrative psychotherapy. This narrative approach uses therapeutic techniques to inform assessments of suicidal risk, but in collaborative ways that can sustain hope. Aside from adding first-person evidence to the clinical file, it might better enable patients to articulate the extent to which they appreciate the risk of premature death. It might also enable patients to re-evaluate their wish for MAiD. More to the point, it affords patients who profess a wish to die an opportunity to express themselves and be listened to that many of them claim they want to have.