By Anand Kumar and Sally Weinstein
Canada is on the threshold of enacting a law that would make medical assistance in dying (MAiD) accessible to people whose only medical condition is mental illness. If this were to pass, Canada would be one of only a handful of countries to extend that process for patients with serious mental illness.
It will apply to conditions that are primarily within the domain of psychiatry like depression and personality disorders. Political leaders have accused the Trudeau government of promoting a “culture of death;” others see this as a sign of gross underfunding of high demand mental health services.
In the United States, Oregon was the first state to enact the Death With Dignity Act, in 1997. The measure allowed terminally ill adults to end their lives by voluntarily self-administering lethal doses of medication prescribed by a physician for that purpose, with key caveats that included a physician’s diagnosis of terminal illness leading to death within six months. Since then, the District of Columbia and nine additional states have enacted laws that facilitate medication assisted death along the lines of the Oregon model.
Societal expectations regarding MAiD evolved over time. Several European countries have broadened the scope beyond terminal illness and imminent death to include suffering, functional decline and unbearable circumstances with no prospect of improving with treatment, thereby incorporating quality of life metrics into the process.
In a potentially dangerous expansion, countries including Switzerland, the Netherlands, Belgium and Luxembourg currently permit medical assistance in dying for patients characterized as having severe and persistent mental illness (SPMI) — defined as conditions resistant to evidence-based treatments — provided they meet additional criteria that include intolerable suffering with preserved decision-making capacity. By expanding into the realm of mental illness, we change the fundamental nature of the discussion.
Serious mental disorders are in essence brain disorders that are influenced by psychosocial factors. Unlike neurologic diseases, mental disorders cannot be localized to specific regions of the brain. Neuroimaging studies of patients diagnosed with SPMI, including bipolar disorder, the schizophrenia spectrum, anorexia, and post-traumatic disorder, for example, demonstrate that multiple brain regions are involved in the development of these illnesses. These disorders are mediated by impaired brain circuits — interconnected brain regions — rather than any specific part of the brain. The region most consistently involved in these circuits is the prefrontal cortex, which mediates executive functions.
Executive functions include judgment, abstract thinking, planning, integrating information from all brain regions and insight. These domains are therefore compromised in patients with SPMI, with important downstream behavioral consequences that include impaired insight into the nature of their illness and loss of the ability to objectively consider the pros and cons of intervention.
This is not to suggest that all patients with SPMI have minimal insight or are incapable of making rational decisions about their health care. Far from it. But it must be acknowledged that not all diseases, not even all brain disorders, are the same, and some of them do adversely impact cognitive domains germane to consequential decision-making.
There are effective treatments, both pharmacological and psychotherapeutic, that can reduce the burden of disease and improve the quality of life for patients with mental illness. Some of them require long treatment trials using traditional approaches or with newer neuromodulation techniques, such as transcranial magnetic stimulation.
A major compounding factor for patients with SPMI is the lack of adequate access to psychiatric care. Insurance companies frequently use a ‘business model’ approach that maximizes profit; for those with insurance, especially publicly funded insurance that is increasingly privatized, payment is often denied or limited. Denial of care exacerbates the challenges patients face as they navigate our health care system and potentiates the desire for an “exit plan.” Like the current debate in Canada, adequate mental health services and access to care will serve as mitigating factors favoring life in a subgroup of patients.
The notion that there is a right dose and combination of medications for all patients that will eventually result in symptom remission is more folklore than science. We must be intellectually honest and acknowledge that not all forms of SPMI are curable with appropriate therapy and that some patients remain refractory to treatment even after repeated attempts. Patients may also be overwhelmed by long medication trials and experience hopelessness about clinical remission, which is difficult to disentangle from the very symptoms of these illnesses. Perseverance is often a long game in clinical medicine.
An option for this group would be palliative psychiatry. Palliative medicine — that is, the absence of active medical interventions while providing basic sustenance and support — is more widely appreciated in cases of cancer and other near terminal illnesses where the patient makes an informed decision that quality of life, brief as it may be, is more important than measures to extend life, especially when they cause undue discomfort. Palliative approaches in psychiatry are conceptually comparable and include accepting that severe mental illness can be incurable, avoiding direct treatments with challenging side effects and questionable impact, and offering a support system that helps patients live impactful lives until death.
The American Medical Association’s Code of Ethics maintains that assisting in death violates a fundamental code for medical practitioners. The American Psychiatric Association adopted the same position as the AMA in 2016, stating “a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing deaths. Suicide prevention is the bedrock of mental health care throughout the country.”
The debate is clearly a difficult one, fraught with emotions; it needs to incorporate not only new scientific information but also the cultural values and principles of the society in which we live. The relationship between patients with mental illness and the practice of medical assistance in dying is a slippery slope that is likely to get even more slippery over time. We will require great caution and a thoughtful national debate as we move forward.
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