Mark Sinyor is a psychiatrist and suicide prevention researcher at Sunnybrook Health Sciences Centre. Ari Zaretsky is chief of the department of psychiatry at Sunnybrook.
Earlier this year, the federal government expanded physician-assisted death laws to apply to people with chronic medical problems even if they have years or decades to live. Unbeknownst to many, it also set up a process that will almost certainly result in death becoming available, in the near future, as an intervention for chronic mental illnesses. This is destined to create a massive legal quagmire, which, unfortunately, hasn’t got the attention it deserves. Importantly, these are not issues that the government’s forthcoming recommendations, set to be released by this coming March, will be able to resolve.
Let’s consider a practical example. A 22-year-old woman with bipolar disorder has struggled with her illness for a decade with no relief despite treatment. She sees a psychiatrist who decides that there is no way to relieve her suffering and a doctor ends her life against the wishes of her parents. Her parents then sue the psychiatrist for malpractice. Their lawyers call scientific experts, who testify that the psychiatrist’s assessment that there was no way to relieve her suffering really couldn’t be made with existing evidence. With the psychiatrist on the stand, their lawyer offers a stinging challenge: “Doctor, you made a determination that is considered medically impossible, given the best available science, and now my clients’ daughter is dead.”
None of us would wish to be in the shoes of the psychiatrist in this scenario. The issue is that, despite much discussion and rhetoric, there is essentially no science behind the practice of physician assisted death for mental illness. There has never been a study examining how often intolerable suffering exists after comprehensive psychiatric treatment, let alone whether psychiatrists have any ability to accurately predict when that might be the case (as would be required by Canadian law). We don’t even have a proper scientific definition for the concept of “enduring and intolerable suffering,” which is at the crux of the legislation.
If our government endorses death as a means of coping with mental illness, this could have a tragic impact on many areas of mental-health care, including suicide prevention. In a vacuum of scientific evidence, we are in extreme danger of breaching one of the foundational ethical dictums of medicine: “First, do no harm.”
New treatments must be studied, with benefits shown to outweigh risks, before delivering them to the public. Usually, the Health Canada approval process compels the health care community to perform its due diligence prior to approving a new intervention. But decisions about physician assisted death in Canada were made in courts and Senate hearings where the usual scientific rigour was not mandatory. Instead, we had a Kafkaesque scenario where handwaving arguments based on missing or unacceptably poor-quality data were presented to courts and legislators as scientific facts. This provided false reassurance that no harm would come to Canadians. As physicians who care about our patients and expect psychiatry to adhere to the highest scientific standards, this was painful to watch.
The Centre for Addiction and Mental Health, the Canadian Mental Health Association, the Canadian Association for Suicide Prevention and the Expert Advisory Group on Medical Assistance in Dying have all released statements highlighting that we currently lack the knowledge to determine whether a particular person’s suffering in mental illness can be remedied. This means that, on a practical level, physician assisted death for mental illness cannot be legal in Canada. But a relatively small group of vocal psychiatrists is readying to push forward as soon as the law is expanded (likely in early 2023). This is a broken process.
As mood disorders experts, we regularly witness patients recovering and living meaningful lives even after severe illness that appeared untreatable. Sometimes recovery can take years because it requires the right mix of biological and psychological treatment, a relationship with a caring professional, and a social support system. This is why studies are so urgently needed. It is unethical to create a process that will populate cemeteries with such patients under the guise of respect for patient autonomy because we failed to conduct the research necessary for truly informed decisions. It would be unconscionable to withhold potential evidence that our patients’ seemingly hopeless suffering can be alleviated. Courts might also rightly view it as illegal.
When patients come through our doors, they correctly expect to be speaking to experts. If we tell them that their suffering cannot be relieved, they ought to be confident that such determinations have a basis in evidence and science, especially when the alternative offered is death. An appeal for proper scientific investigation prior to implementation of a proposed medical treatment should not be controversial in the 21st century. Let’s not wait for the courts to point out our folly.
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