As Canada prepares to usher in a new legislative framework governing assisted dying, a contentious question remains as to whether such a course of action ought to be extended to individuals with psychiatric conditions. In Carter v. Canada (Attorney General) (2015 SCC 5), the Supreme Court of Canada stipulated that assisted dying will be available to competent adults who:

1. clearly consent to the termination of life; and
2. have a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of the condition.

It is unclear whether these criteria are applicable to psychiatric conditions in otherwise healthy individuals.

Last week, JAMA (The Journal of the American Medical Association) Psychiatry published a study that may shed some light on individuals with psychiatric conditions seeking to access assisted dying. According to the study, which examined 66 case summaries of requests for euthanasia or assisted suicide among patients with psychiatric disorders occurring in the Netherlands between 2011 and 2014, psychiatric assisted dying is increasing in prevalence. The study shows that patients receiving euthanasia or assisted suicide for psychiatric conditions are mostly women and of diverse ages. While depressive disorders were the primary issue in more than half of the cases, other conditions included psychosis, post-traumatic stress disorder or anxiety, and neurocognitive impairment. Conditions such as eating disorders, grief and autism were also observed. As the study’s authors point out, while ethical discourse tends to focus on the issue of treatment-resistant depression as a precursor to psychiatric assisted dying in otherwise healthy individuals, “the reality is more complicated.” For example, the study indicates that the typical individual making use of this course of action possesses “various chronic psychiatric conditions, accompanied by personality disorders, significant physical problems, and social isolation or loneliness.”

In reflecting on the complicated role of physicians in assessing the broad criteria for access to euthanasia and assisted dying in the Netherlands, the JAMA Psychiatry study’s authors note that applying such criteria to individuals with terminal illness “arguably requires less judgment than in psychiatric cases because the eventual prognosis of individuals with terminal illness is not in question”. By contrast, factors such as uncertain prognosis and complicated notions of medical futility surrounding the issue of treatment refusals in psychiatric patients likely render physician judgment in such cases a precarious task. Variability in physician judgment was apparent in the study, in which almost one-third of patients were refused access to euthanasia or assisted suicide, and almost one-quarter of cases generated disagreement among the physicians involved. The study’s authors conclude that individuals requesting euthanasia or assisted dying in the context of psychiatric disorder are complicated and suffering, and that such requests frequently require considerable judgment on the part of physicians.

As the JAMA Psychiatry study illustrates, little is known about individuals seeking assisted dying for psychiatric conditions. Moreover, commentators have expressed concern that allowing individuals with psychiatric disorders to access assisted dying could result in troubling consequences, such as allowing assisted dying to serve as a substitute for effective psychosocial intervention in the context of difficulties like loneliness or isolation. Ultimately, it is clear that physicians will have a challenging role to play when it comes to assessing patients with psychiatric issues who have requested assisted dying. It remains to be seen how this issue will play out as Canada seeks to navigate this complicated new terrain.