Medical Assistance in Dying: Challenges for Psychiatry

Assisted death for prisoners and forensic patients: complexity and controversy illustrated by four recent cases

Medical assistance in dying (MAiD) (which includes euthanasia and assisted suicide) is available in an increasing number of countries. In Belgium, The Netherlands and Switzerland (and was due to be implemented in Canada from 2024) eligibility includes mental suffering in the absence of any physical disorder. There are particular ethical and legal issues when considering MAiD for those involuntarily detained in prisons and hospitals. We describe four recent cases that illustrate these complexities, and highlight issues of equivalence of healthcare and self-determination against concerns about the criteria for determining eligibility of those with non-terminal conditions as well as the objections raised by victims and families and the demands for justice.

Persons with mental disorders and assisted dying practices in Spain: In response to Ramos et al

Ramos et al. paper offers a narrative review of Spanish Organic Law 3/2021, which regulates euthanasia, focusing on its application to individuals with mental disorders. Ramos et al. examine the application of legal prerequisites from an ethical-legal perspective to ascertain the conditions under which psychiatric euthanasia might be considered legitimate and compliant with legal stipulations. Nevertheless, it is apparent that the core ethical inquiries linked to this matter have not been exhaustively investigated. The criteria laid out are, in our assessment, still open to further debate and broader deliberation. Our article emphasizes the need for a comprehensive ethical and legal debate in Spain regarding psychiatric euthanasia. Competency assessment is central to the legislation, but there are concerns about the validity of assessment tools and the subjective nature of interviews. Furthermore, defining irreversible suffering in mental health contexts poses challenges. The article advocates for a deeper understanding of the needs of individuals with mental disorders before considering euthanasia and emphasizes the importance of comprehensive care and psychosocial interventions in reducing the desire for euthanasia. Ultimately, it underscores the ethical complexities of euthanasia in mental health and the necessity of prioritizing comprehensive care in addressing these complexities.

Medical assistance in dying for people living with mental disorders: a qualitative thematic review

BACKGROUND

Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be successfully introduced and implemented, where legislations allow it.

METHODS

Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders' well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria.

RESULTS

Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders.

CONCLUSION

The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD.

Making a case for the inclusion of refractory and severe mental illness as a sole criterion for Canadians requesting medical assistance in dying (MAiD): a review

BACKGROUND

Following several landmark rulings and increasing public support for physician-assisted death, in 2016, Canada became one of a handful of countries legalising medical assistance in dying (MAiD) with Bill C-14. However, the revised Bill C-7 proposes the specific exclusion of MAiD where a mental disorder is the sole underlying medical condition (MAiD MD-SUMC).

AIM

This review explores how some persons with serious and persistent mental illness (SPMI) could meet sensible and just criteria for MAiD under the Canadian legislative framework.

METHODS

We review the proposed Bill C-7 criteria (capacity, voluntariness, irremediability and suffering) as well as the nuances involved in separating a well-reasoned request for assisted suicide from what might be solely a manifestation of a SPMI.

FINDINGS

In this paper, we argue against the absolute exclusion of patients with SPMIs from accessing MAiD. Instead, we propose that in some circumstances, MAiD MD-SUMC may be justifiable while remaining the last resort. Conducting MAiD eligibility assessments removes the need to introduce diagnosis-specific language into MAiD legislation. Competent psychiatric patients who request MAiD should not be treated any differently from other eligible candidates. Many individuals with psychiatric disorders will be incapable of consenting to MAiD. The only ethical option is to assess eligibility for MAiD on an individual basis and include as legitimate candidates those who suffer solely from psychiatric illness who have the decisional capacity to consent to MAiD.

Suicide Distribution and Trends Among Male Older Adults in the U.S., 1999-2018

INTRODUCTION

This study examines the distribution and trends in suicide death rates among male adults aged ≥65 years in the U.S. from 1999 to 2018.

METHODS

Suicide mortality data were derived from Multiple Cause of Death from the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research database. Suicides were identified from the underlying causes of death. Joinpoint regression examined the distribution and shift in suicide age-adjusted death rates overall and by age groups, race/ethnicity, method of suicide, and urbanicity. Analyses were conducted in 2020.

RESULTS

Between 1999 and 2018, a total of 106,861 male adults aged ≥65 years died of suicide (age-adjusted rate=31.4 per 100,000 population, 95% CI=31.2, 31.6). Suicide rates showed a V-shaped trend. They were declining annually by 1.8% (95% CI= -2.4, -1.2); however, starting in 2007, there was a shift upward, increasing significantly by 1.7% per year for the next decade (95% CI=1.0, 1.6). Suicide rates were highest among those aged ≥85 years (48.8 per 100,000 population with an upward shift in 2008), Whites (35.3 per 100,000 population with an upward shift in trend in 2007), and the most rural communities (39.0 per 100,000 population). Most suicides were due to firearms (78.3% at a rate of 24.7 per 100,000 population), especially in rural areas, and shifted upward after 2007.

CONCLUSIONS

Increases in suicide rates among male older adults in the U.S., particularly after the 2007-2008 economic recession, are concerning. Tailored suicide prevention intervention strategies are needed to address suicide-related risk factors.

Survey of Mental Health Care Providers’ Perspectives on the Everyday Ethics of Medical-Aid-in-Dying for People with a Mental Illness

Context: In most jurisdictions where medical-aid-in-dying (MAiD) is available, this option is reserved for individuals suffering from incurable physical conditions. Currently, in Canada, people who have a mental illness are legally excluded from accessing MAiD. Methods: We developed a questionnaire for mental health care providers to better understand their perspectives related to ethical issues in relation to MAiD in the context of severe and persistent suffering caused by mental illness. We used a mixed-methods survey approach, using a concurrent embedded model with both closed and open-ended questions. Findings: 477 healthcare providers from the province of Québec (Canada) completed the questionnaire. One third of the sample (34.4%) were nurses, one quarter psychologists (24.3%) and one quarter psycho-educators (24%). Nearly half of the respondents (48.4%) considered that people with a severe mental illness should be granted the right to opt for MAiD as a way to end their suffering. Respondents were more likely to feel comfortable listening to the person and participating in discussions related to MAiD for a mental illness than offering care or the means for the person to access MAiD. Most (86.2%) reported that they had not received adequate/sufficient training, education or preparation in order to address ethical questions surrounding MAiD. Conclusions: The findings highlight how extending MAiD to people with a mental illness would affect daily practices for mental healthcare providers who work directly with people who may request MAiD. The survey results also reinforce the need for adequate training and professional education in this complex area of care.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.

Perceived Burdensomeness and the Wish for Hastened Death in Persons With Severe and Persistent Mental Illness

Background: In several European countries, medical assistance in dying (MAID) is no longer confined to persons with a terminal prognosis but is also available to those suffering from persistent and unbearable mental illness. To date, scholarly discourse on MAID in this population has been dominated by issues such as decision-making capacity, uncertainty as to when a disease is incurable, stigmatization, isolation, and loneliness. However, the issue of perceived burdensomeness has received little attention. Objective: The study explores the possible impact of perceived burdensomeness on requests for MAID among persons with severe and persistent mental illness (SPMI). Method: Using the method of ethical argumentation, we discuss the issue of access to MAID for persons with SPMI and perceived burdensomeness. Conclusion: Perceived burdensomeness may be a contributing factor in the wish for hastened death among persons with SPMI. MAID is ethically unsupportable if SPMI causes the individual to make an unrealistic assessment of burdensomeness, indicating a lack of decision-making capacity in the context of that request. However, the possibility that some individuals with SPMI may perceive burdensomeness does not mean that they should be routinely excluded from MAID. For SPMI patients with intact decision-making capacity who feel their life is not worth living, perceived burdensomeness as a component of this intolerable suffering is not a sufficient reason to deny access to MAID.

Compulsory Psychiatric Admission in a Patient With Metastatic Breast Cancer: From Palliative Care to Assisted Suicide

The provision of palliative care in psychiatry and the use of coercion in palliative care are underexplored areas. We report the case of a 65-year-old woman with cerebral metastatic breast cancer who was compulsorily admitted from a specialized palliative care ward to a psychiatric inpatient ward in Zurich, Switzerland. While in specialized inpatient palliative care, the patient had resisted palliative care but was found to lack decision-making capacity for her treatment due to disordered thought process and paranoid delusions. Under our care, which involved coercive treatment in the form of concealed administration of an antipsychotic, the patient's psychiatric symptoms improved. She regained decision-making capacity, was granted discharge from hospital, and ended her life by assisted suicide on the day of discharge.