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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Christianity Versus Personal Responsibility

No deep insights here. Just a big, bold WTF? at the fact that so many conservative Christians continue to profess to be champions of personal responsibility.

Really?

Christians: your god hates personal responsibility. He loathes it. If you believe he exists and if you believe Christian doctrine, then this god has condemned you to torture because of something someone else did thousands of years before you were born. That’s not personal responsibility. If that god believed in personal responsibility, Eve and Adam would have taken some lumps – presumably the snake also – and, well, that would be it. They were cast out of the garden. Their children didn’t return, so no one else ate the forbidden fruit. Nope. Just those two. But the Christian god is happy to make you responsible for events in which you played no personal part.

And, of course, there’s no responsibility imposed on you for your evil acts. Sure, you have to “believe” in the Big J, but even if you don’t commit any evil acts, you’d still have to have faith in order to escape torture. To escape divine condemnation, Stalin must pay the same price (no more, no less) that any child who dies within minutes of being born must pay. No need to make amends to those you’ve wronged. No need to do something a little extra to make it back into the Christian god’s good graces if you ordered water boarding and other war crimes. No need to suck up just a little bit more if you launch a war that kills hundreds of thousands of people.

Nope. This god condemns regardless of your behavior. This god condemns regardless of the amount of evil you harbor. And this god forgives Hitler and Mother Teresa just as quickly and easily as this god “forgives” Charles Hamilton Houston, Sylvia Rivera, Hildegard von Bingen, and Woody Guthrie.

Personalized responsibility? Responsibility where it actually matters what you personally have done, why you did it, and what outcomes resulted? That’s anathema to the Christian god and antithetical to the tenets of Christianity.

And yet so many people simultaneously profess to be devout Christians and believers in personal responsibility. I sometimes wonder: do they even realize that they must of necessity be lying about at least one of those things?

Talk About a Mediocre Ethicist

In the last post all about me, I mentioned that it might be possible for any mediocre ethicist to outdo anything I have accomplished. Recently I read all too many articles published by the Christian Courier, all of which, strangely, list Wayne Jackson as their author.

And? I stand corrected. I have found a Black Swan: at least one mediocre ethicist has no hope of outdoing me.

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A Moral Caricature: Deontology

How do you make your moral decisions? I’m not asking which things you think are good and which things you think are bad. I’m asking what factors do you consider, and what is the process by which you consider them, when you are trying to figure  out what is right or wrong, good or bad?

The online comic Strong Female Protagonist stars a superhero like many others in a story unlike many others. For those who remember Concrete, SFP reminds me more of that book than any other super hero comic I know. Recently, the main character had to make some decisions that any real person would spend some time second guessing. She wondered if she made the right choices. She wondered if she could even be called a hero. And yet, she wasn’t certain that choosing anything else would have been any better. All this is good. All this is appropriate characterization. But these thoughts are thoughts that in other comics would have been dealt with, if at all, in a dramatic moment. Either the hero would mull ethics immediately after a battle while in the midst of unignorable devastation caused by the battle, or the ethics would be glossed over until the middle of the next big battle, when suddenly the hero would seize up and the drama wouldn’t be so much about the goodness of the character as the timing of the character breaking free of the paralysis.

But Strong Female Protagonist is not a typical super hero story. Our Hero ends up wrestling with these questions in the park, speaking to an old professor she ran into by happenstance. One of the themes you’ll see explored here on Pervert Justice will be meta-ethics: how do we make decisions about what is good and what is bad? The creators of SFP did an excellent job with the hero/professor conversation and so I thought I’d take the opportunity afforded by this story to begin a discussion on meta-ethics.

We’ll start just with this one story-page to get a glimpse of a number of major considerations one encounters when attempting to consciously craft a meta-ethics that works with one’s own values and perspectives and experiences. On this page, the hero’s old professor (black hair) is drawn coat-on to represent one side of an ethical debate while the professor is drawn coat-off to represent the other side of the same debate. Our Hero is drawn in the middle of this debate, focussed on listening:

A Page from Strong Female Protagonist where our hero listens to one professor play-act both sides of the Deontology vs Consequentialism debate.

This is one of the first questions we must solve in meta-ethics: will we consider results alone? Or will we consider other factors? Note that consequentialism and especially Utilitarianism (one instance of consequentialism) are not the only systems of ethical decision making that consider the results (or the ends) of an action. Deontology, which is made up of those ethical systems that prioritize following rules or adhering to duties, is frequently asserted to be a system of following rules instead of considering consequences. This, however, is a caricature. Not only are consequences considered at various points in deontic reasoning, but an appeal to consequences is frequently a justification for imposing duties in the first place.

How else would you describe the first argument on the page?

CoatOn: If the ends justify the means, then all is permitted! In the name of the Greater Good we may commit any atrocity we like.

CoatOn is arguing for considering factors other than results, but the argument is that if we fail to examine the means and not merely the results, then we will end up with bad results. This is a Deontic position, a position that ethics is best described as a set of duties and the relationship of individual decisions/actions to those duties. Yet it is not blind to consequences. Rather it asserts that we will get better consequences if we begin our ethical decision making already constrained by certain duties. These duties are different in different deontic systems. In some an important duty/value (often the most important duty/value) is obedience to some authority, typically a god. But not all deontic ethical systems are religious and not all religious ethical systems are deontic.

Consequentialism is typically seen in contrast to deontology. There are other ethical decision making systems to consider, but the most frequently debated today reside in one of these two camps. For now, it’s enough to distinguish deontology from consequentialism and to understand that deontologists don’t ignore consequences, but rather have a belief (sometimes presuppositional) that the best ethical decision making is a process that considers more than consequences alone.