Should Suicidal Clients Have the Right to Die?

By Jordan Mayfield, LSCSW, LCAC

The idea of euthanasia has been a hotly contested topic throughout North America for many years. Canada is currently one country that allows for medical assistance in dying (MAID). And it’s about to become even more controversial. Currently, Canada prohibits MAID for persons whose sole diagnosis is a mental health condition, according to the government’s website. This mental health exclusion is set to expire in March 2024, although new legislation could be introduced to extend this exclusion for another year.

The current criteria, outlined on the website, to obtain MAID are the following:

• have a serious illness, disease or disability (excluding a mental illness until March 2024)

• be in an advanced state of decline that cannot be reversed

• experience unbearable physical or mental suffering from your illness, disease, disability or state of decline that cannot be relieved under conditions that you consider acceptable

You do not need to have a fatal or terminal condition to be eligible for medical assistance in dying. Additionally, “The original temporary exclusion was intended to provide the Government of Canada and health professional bodies time to advance and implement appropriate clinical guidance for safely assessing and providing MAID to those whose only medical condition is a mental illness.” It appears that Canada is planning to begin allowing MAID for persons who only have mental health diagnosis(es) at some point in the future.

As a mental health professional who has been trained to assess, report, and help prevent people from attempting and/or completing suicide, the idea of medical professionals aiding in this process is an interesting one. Currently the American Medical Association asserts that it is against the medical practitioners’ code of ethics to assist in a patient’s death. According to Healthline, the fact that depression is in most cases a treatable condition AND includes thought impairment as a major symptom, influence this stance.

In the United States the District of Columbia and seven other states allow MAID but do not allow it for those with mental illness as their primary or sole diagnosis. According to Biomed Central there are currently six countries that allow MAID and include mental health diagnoses as viable conditions to allow for this procedure. Additionally, four of those countries allow this procedure to occur in minors. Their research includes looking into individuals diagnosed with personality disorders which often include pervasive thoughts of suicide. “These studies suggest that most clinicians who grant EAS have indeed perceived their patients’ suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments.”

There are two ways in which medical professionals participate in MAID. One of those ways is to directly administer a lethal injection resulting in a person’s death. The other is prescribing medications and instructions for the patient to administer themselves. As a mental health professional, the question remains, if the person is suffering with mental illness and suicidal ideation only, is this ethical?

There are several mental health diagnoses in which suicidal ideation can be present. Most commonly though it is considered to be associated with depression. According to 2022 data, over 19 million people in the U.S. are living with depression, and the National Institute of Mental Health reports that 80% of people who get treatment report feeling better. Treatments for depression generally include lifestyle changes such as exercise and sleep hygiene, medication, support groups and/or therapy. Additionally, there has been increasing evidence that the following interventions help with depressive symptoms as well: somatic interventions such as EMDR, brain-spotting and even yoga; micro-dosing of certain controlled substances such as psychedelics (under supervision); hypnotherapy; meditation; and TMS which is “ a noninvasive technological breakthrough that involves applying a series of short magnetic pulses to stimulate nerve cells in areas of brain known to be associated with major depression” according to the University of California San Diego.

A 14-year longitudinal study published in 2020 gathered data of the diagnoses associated with the highest risk of suicide. The study shows that those with diagnosed psychotic disorders such as schizophrenia, schizotypal and delusional disorders are at the highest risk of suicide attempts and completion. A psychotic disorder is primarily defined by “abnormal thinking and perceptions.” If disordered thinking is the main symptom of this disorder, are those individuals capable of informed consent associated MAID? Additionally, most research, including UW Medicine, suggest that psychosis is treatable. The most common and effective treatment is anti-psychotic medication followed by psychotherapy and case management services. Early intervention for psychotic symptoms is paramount and currently the average time between symptom onset and treatment is around 18 months. Schizophrenia and other similar diagnoses are not life sentences. These individuals “can live full, meaningful lives. They can get work, get married, have kids, and do the same things everyone else does in life.”

In a study published by the Neuropsychiatry and Clinical Neurosciences Journal, the authors’ note that “the greatest functional impairment of these illnesses on the lives of the mentally ill and society are not related to the symptoms of delusions, hallucinations, or depressed mood, but simply to making poor decisions.” This can be particularly true of those experiencing depression whose negative thinking and excessive guilt and shame distort their view of self and include making decisions that are detrimental to them. Herbert Simon identified three steps of rational decision making. “(1) identification and delineation of all alternatives, (2) determination of the consequences of each alternative and (3) a comparison of the accuracy and efficiency of each of these sets of consequences.” Would an individual experiencing delusions and/or cognitive distortions associated with depression have the same capacity to make rational decisions as a person not experiencing those symptoms?

According to the National Institute of Mental Health to be determined legally “insane” for purposes of prosecution there is an assumption at the time of the crime that the person was “incapable of appreciating the nature of the crime and differentiating right from wrong behavior, hence making them not legally accountable.” It would be expected that individuals seeking MAID would not meet this definition of incapacity as most mentally ill people do not. And if they did, I would assume it would not be granted. But on the continuum of mental illness and impairment where does a person’s right to self-determination end and their perceived incompetence begin?

The concept of self-determination is very important in the mental health field. This idea refers to a person’s right to make choices related to the trajectory of their life. Very Well Mind identifies the components of self-determination as autonomy, competence, and connection. As a therapist, self-determination significantly influences my practice. I do not decide for a client what I think their treatment goals should be. Instead, I take the client’s identified goals for their life, engage them in conversation about how to achieve them and provide feedback when necessary. Generally speaking, a client’s goals are their own and it is not my job to judge them. If, upon further assessment their goal seems to be exacerbating or continuing their mental health symptoms than this becomes a topic for conversation. But ultimately, mental health treatment is a treatment that requires informed consent and the client’s goals steer the ship.

When the stakes are literally life and death in medical assistance in dying decisions how do we clinically and ethically determine a person’s right to choose? Like all medical decisions, it seems that allowing this decision to be between the client and their medical professional(s) is the best choice. Unilaterally allowing or banning this procedure will limit self-determination. It will also prohibit medical professionals from making decisions with their clients that are potentially most appropriate for their case.