Are Concerns About Irremediableness, Vulnerability, or Competence Sufficient to Justify Excluding All Psychiatric Patients from Medical Aid in Dying?

Abstract

Some jurisdictions that have decriminalized assisted dying (like Canada) exclude psychiatric patients on the grounds that their condition cannot be determined to be irremediable, that they are vulnerable and in need of protection, or that they cannot be determined to be competent. We review each of these claims and find that none have been sufficiently well-supported to justify the differential treatment psychiatric patients experience with respect to assisted dying. We find bans on psychiatric patients' access to this service amount to arbitrary discrimination. Proponents of banning the practice ignore or overlook alternatives to their proposal, like an assisted dying regime with additional safeguards. Some authors have further criticized assisted dying for psychiatric patients by highlighting allegedly problematic practices in those countries which allow it. We address recent evidence from the Netherlands, showing that these problems are either misrepresented or have straightforward solutions. Even if one finds such evidence troubling despite our analysis, other jurisdictions need not adopt every feature of the Dutch system.

Irremediable Psychiatric Suffering in the Context of Physician-assisted Death: A Scoping Review of Arguments: La souffrance psychiatrique irrémédiable dans le contexte du suicide assisté : Une revue étendue des arguments

“…Rooney et al argue that irremediability can be predicted for individual depressed patients with help of staging models. 36 A questionnaire in 2016 among 248 Dutch psychiatrists found that 70% disagreed with the statement that it is impossible to assess whether a psychiatric patient suffers irremediably and unbearably, 12% agreed with this statement, and 17% was neutral. 50 In the ethical debate, however, many authors argue that it is impossible to reliably differentiate between patients who have a chance of recovery and those who do not.…”

“…(2) Because of the episodic nature of some mental illnesses, a 1-year waiting period should be considered in the case of mental illness. Rooney et al 36 Case report (1) It is possible to determine whether psychiatric suffering is irremediable. 2The relative long survival of psychiatric patients who suffer irremediably makes exclusion from PAD especially harmful.…”

“…15 Other proponents of PAD argue that the harm of letting a majority of truly irremediable patients suffer could be greater than the voluntary death of a minority that might recover spontaneously or benefit from future treatment. 21,24,36 Also, the nonlethality argument is disputed altogether, as patients may die through suicide, which may be regarded as worse than dying through PAD. 36 A third viewpoint balances these 2 positions, arguing that a reasonable level of uncertainty can be acceptable.…”

“…21,24,36 Also, the nonlethality argument is disputed altogether, as patients may die through suicide, which may be regarded as worse than dying through PAD. 36 A third viewpoint balances these 2 positions, arguing that a reasonable level of uncertainty can be acceptable. 20,45 What counts as reasonable depends on the situation and has to be determined through dialogue between doctor and patient.…”

Too much safety? Safeguards and equal access in the context of voluntary assisted dying legislation

“…These patients' potential entitlement, while beyond the scope of this paper, is important to consider and there has been extensive and continuing ethical discussion about who ought to be eligible for voluntary assisted dying (e.g. [18][19][20][21][22]). However, our focus in this paper is not on equal access in the sense of the justifiability of the Victorian eligibility criteria.…”