Anxiety, Depression and Medically Assisted Suicide

In the past week, a Canadian law regulating the exercise of the right to medical assistance in dying (that right being established by a Supreme Court of Canada decision known as Carter) has come into effect. Although I host far from the most regular blog on FtB, and although that inevitably results in fewer comments here than elsewhere, I’d like to try to host a discussion on an important topic of ethics and law: whether treatment-resistant anxiety disorders and/or treatment resistant depression should have access to medically assisted suicide.

In Canada, the Carter decision has established that the privacy/autonomy right so crucial to the Supreme Court’s decisions establishing a right to abortion access in the Morgentaler cases also encompasses the right of “grievously and irremediably ill persons” to gain access to advice and medications necessary for competent assisted suicide as well as to further medical aid in dying (sometimes called MAID though something about this acronym sounds unpleasantly inappropriate to me). Grievous and irremediable illness is not a phrase that automatically excludes mental illness, and indeed one person has already gained access to medical aid in dying on the basis of severe and treatment-resistant mental illness.

However, this first person known to have access to medical aid in dying on the basis of psychiatric illness suffered from a conversion disorder. Conversion disorders are so called because although as best can be discerned by physicians the symptoms arise from a psychiatric basis, the psychiatric and/or psychological problems manifest in distinctly physical ailments: literal paralysis and serious digestive difficulties that can result in malnutrition are two of the most severe noted effects of conversion disorders.

The Carter decision does not require (as does the state of Oregon’s Death With Dignity Act, see ORS 127.800) that natural body processes will foreseeably lead to death as a result of the grievous and irremediable illness. In Oregon, you must have a prognosis limiting your expected lifespan to 6 months. In Canada, this is not true. Thus for diseases that dramatically affect quality of life, are incurable, and may indeed lead to death but with ordinary treatment will only do so in a matter of years, if not longer, Canadian law now provides for the possibility of medical aid in dying.

Mental illness is nominally handled differently in the Carter decision and in Oregon’s DWDA: in Oregon’s law mental illness cannot make you eligible, except in the possible case of a person whose body is literally failing as a result of a conversion disorder or something similar. Though one cannot be eligible for use of the DWDA’s provisions on the basis of mental illness, mental illness is not automatically a bar to such access for Oregonians who have a terminal illness co-occur with a psychiatric one. The Canadian approach, as required by the Carter decision and implemented by the Liberal bill C-14, is significantly different.

In Canada, a psychiatric illness on its own can qualify a person for medical assistance in dying even where the illness is not directly causing body, organ, or metabolic failures that will (unchecked) result in death. In practice, however, the courts have to date only approved one petition for medical aid in dying based on mental illness, the case detailed above. A similar case in which a man asked for medical aid in dying on the basis of a similar cluster of mental illnesses (including a conversion disorder causing physical symptoms sufficient to cause true distress in anyone regardless of ultimate cause) is known to have been denied. With two data points it’s not yet possible to establish a pattern in how Carter and C-14 will be implemented, but it may be that the cases appeared distinct to the courts in part because the physical symptoms for the man whose petition was denied were less severe and that more of the distress emphasized in court arguments by the petitioner was related to psychological suffering. Another factor may be that the person whose petition was approved was over 50 while the person whose petition was denied was under 30.

Despite the paucity of data, however, I’m willing to speculate that in practice the interpretation of Canadian law is going to look more like Oregon law than first appears: psychiatric conditions that do not cause death on their own (even if they frequently cause behaviors that can result in death) are much less likely to be accepted as legitimate grounds for medical aid in dying.

But should that be the case? We know that depression, PTSD, and anxiety disorders come in more severe and less severe forms. We know that for some persons symptoms will pass on their own. We know that some therapies can reduce the time required for symptoms to pass, make recurrences less frequent, and make recurrences less severe. And we also know that for some persons the suffering continues largely unaffected by available therapies.

There are cases where enough time and effort has passed that qualified medical practitioners can competently assert that there is no longer any untried treatment with any likelihood of success. In those cases, if and when a patient requests medical aid in dying, should that aid be provided? In Canada the law does not preclude it in clear language, though practice appears to frown on such a possibility. In Oregon the law does preclude it.

Is one of these approaches better than the other?

I ask a question about law, but fundamentally this is about ethics, love, and community. What should the law be if that law is to promote the best society we are currently capable of creating?

I would not want a law that devalues the lives of those of us with mental illnesses, but I’m not sure that treating ALS differently from the most extreme and untreatable depression actually accomplishes a “valuing” that would be absent if treated the same. It was argued that permitting medical aid in dying for obviously terminally ill cancer patients devalued those cancer patients, but I think evidence shows this fear turned out to be unfounded. Why should it be different for extreme and untreatable anxiety disorders?

It should be noted and considered that the person mentioned above who was denied medical aid in dying eventually died of a medication overdose anyway, but because of the lack of legal sanction there were increased risks taken and it would be impossible to say one’s final goodbyes without legal risk to people who learn about a planned death. The loving person who wishes to end hir own life, then, is forbidden in practice from aiding friends and family in accepting the decision and thus lessening the harm to a community.

Illegal suicide carries the risk of failure that is nonetheless medically damaging, prevents communication around end-of-life decisions, and risks increased harm to community. These risks apply just as much to suicides in response to mental illness as they do to suicides in response to cancers or other non-mental illnesses. The logic for reducing these risks – and eliminating them where possible – is every bit as compelling for those suffering “grievous and irremediable” anxiety or depression as it is for those suffering from similarly extreme conversion disorders.

What do we gain, then, from excluding non-fatal anxiety or depression from the category of qualifying conditions? Is that gain sufficient to justify the current state of Canadian law?

In any comments you choose to contribute, please remember that we are speaking about conditions both grievous and irremediable. Comments that choose to conflate those conditions with less serious conditions or with remediable conditions may be moderated/edited and/or deleted by me.

The Honest Christian

I am almost never asked, “Right Reverend Crip Dyke, if some community leader is going to be a self-professed Christian, would you prefer that person be an honest believer or would you rather that person be a nominal Christian that clearly doesn’t believe in the actual teachings of the bible?”

However, that question is clearly asked or implied on the internet many, many times per day. Some think that the believing Christian is harder to reform because they really do believe on faith many non-sensical things that come straight out of the New Testament, the Tanakh, or the ancillary writings included in the Christian “Old Testament”. Often times this carries a presumption that I (really: the random internet atheist subject to the question) will prefer the person easier to deconvert.

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Trash. Pure Trash.

A new comedy called The Little Hours and set in 1349 is based on a book I read as a teenager: The Decameron.*1 That alone was enough to attract my attention. However, when actor Aubrey Plaza’s new film premiered at Sundance it was so well-loved as to get picked up by a significant movie distributor, in this case a subsidiary (specializing in distributing independent films) of a general movie-distribution subsidiary of AT&T. That, too, would have been sufficient to get my notice as a well-funded distribution campaign was sure to put pop-up ads in my browser windows as mainstream release gets closer.

But apparently Bill Donohue at the Catholic League (who was not in attendance at Sundance and thus hasn’t seen the movie unless he’s claiming the Catholic League stole a copy) wanted to make absolutely sure that I saw this movie-set-in-a-convent and based on a collection of short stories that is to medieval Italian literature what The Cantebury Tales is to medieval English literature. And so, without seeing this film about hiding out in a convent while on the run and encountering stereotype-defying nuns who (nonetheless?) are kind and generous with their shelter and the silly hijinks dreamed up by a medieval Italian Catholic that ensue, Donohue released a statement calling the movie “Trash. Pure Trash.”

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Ken Ham: Just Another Homeboy from the Hood

Ken Ham has frightening ideas of what it means to be anti-racist. Yesterday he declared himself to be “not a white person” adding “there are no black people. Using terms like ‘white’ & ‘black’ promotes division … all are brown”.

While I got this from RawStory where they highlighted a couple of tweets mocking Ham, I think the most interesting and on point criticism that they reported (From AMcBay_NSS: “And using terms like Christian, Muslim, Catholic, Mormon promotes division & prejudice, but that is the intent, isn’t it?”) still came across as missing important nuances of an obviously white person denying the racial system that white people created. It reminds me of the white genocide campaign against the peoples indigenous to (in this case) North America: in the US that consisted in no small part of killing those people who resisted kidnapping, forced placement on “reservations,” and institutional robbery and neglect under a treaty system designed and exploited by white US citizens. But when the terms of those treaties were eventually successfully asserted in court by indigenous persons and tribes and nations, the self-governance provisions that white people used to justify neglect and widespread malnourishment – if not outright starvation – turned out to not specifically exclude autonomy with respect to state anti-gambling laws. Joy! Even though forced onto (frequently valueless and always insufficient in area to support the population) land, and even though white people had told starving members of First Nations across the US that if they wanted to eat, they ought to leave their homes and sovereignty behind, many peoples found a way to use their sovereignty to their advantage and stay in their homes at the same time by building casinos. What did the white folks do? The very same white folks that couldn’t cross the road to feed Indian children because, hey, sovereignty means they get to make their own government and support themselves by themselves? Campaigned against sovereignty.

Of course.

In many places now many more white folks – including me for a time many years ago, though fortunately that was just a stage in learning – feel compelled to assert there is no such thing as race. Though, of course, you didn’t catch very many white people saying that before “Black Power” became a recognizable phrase, before

The Olympic Games were rocked by Black Power – but unfortunately not by Public Enemy.

It is the same phenomenon that leads certain white folks to oppose equal rights protections while screaming in fear that white people might become a minority in their neck of the woods in some dystopian near-future if white women don’t give up this silly notion that they have the right to deny sexual consent to white men.

Ken Ham is a creationist, not an MGTOW internet troll, but Ham and those trolls do have certain things in common, not least how racism has gotten under their skins.