The Debate about Assisted Dying for Persons with Mental Disorders: An Essential Role for Philosophy

The Debate about Assisted Dying for Persons with Mental DisordersAn Essential Role for Philosophy Mona Gupta, MD, CM, FRCPC, PhD (bio) In 20141 and 2016,2 respectively, Québec and Canada adopted legislation permitting medical assistance in dying (MAID). In this context, the question of whether persons with mental disorders should be able to access MAID has received considerable scrutiny. Over the last 5 years, I have been involved in the academic and policy debates about assisted dying for persons with mental disorders. Policymakers and clinicians alike demand that public policy be based on 'evidence' by which they tend to mean empirical, usually quantitative, data. There is little acknowledgement that some questions are not empirical and that facts require interpretation. The debate about whether a request for assistance in dying by a person with a mental disorder is a form of suicidality illustrates this problem. Because suicidality (including thoughts, plans, gestures, and attempts) is strongly associated with certain mental disorders, there are some who argue that a request for assisted dying by a person with a mental disorder is an expression of suicidality, while others argue that suicidality and requests for assisted dying are different phenomena.3 The approach to resolving this debate is to frame the problem as an empirical one. Because it is generally agreed that we should prevent suicide, we should not allow assistance in dying if it is the same thing as suicide. Researchers set about to identify characteristics of persons with mental disorders who are suicidal and those who request assistance in dying. If these two groups share characteristics, it is assumed that those who request assisted dying and those who complete suicide are the same people. If they have different characteristics, the opposite is true. Thus far, there are no characteristics that are specific to all or most members of one group nor are there a sufficient number of common characteristics that apply to all or most members of both groups. With insufficient 'evidence' one way or the other, the debate continues about whether requests for assisted dying by persons with mental disorders are an expression of suicidality. Looking at the concepts at play can clarify the matter. People engage in a variety of different actions that they know may bring about their deaths. These include refusal or non-adherence [End Page 9] to life-sustaining treatment, engaging in highrisk behaviors, or consuming potentially lethal substances to name but a few. Society's responses to these decisions vary. Sometimes society intervenes to prevent these deaths, sometimes it permits death, and sometimes society is neutral. If we think carefully about these different responses and the circumstances to which they apply, we see that suicidality is the term we use precisely to describe those deaths society wishes to prevent. Debating whether suicide differs from MAID is simply restating the issue at stake: is assisted dying for persons with mental disorders something we should accept or prevent? Questioning the meaning and use of concepts lies at the heart of philosophy. Examining how we use the seemingly descriptive term suicide shows it is preceded by a normative judgment. The fact that a person has a mental disorder and expresses an intention to end her life does not tell us what to do. We prevent this person from acting because we have already decided that this is the kind of death we should prevent. Philosophy has a crucial role to play in the debate about assisted dying by circumscribing which issues involve empirical questions, and which ones require normative reasoning. Mona Gupta Mona Gupta is a psychiatrist and clinician-scientist at the Université de Montréal and the Centre Hospitalier de l'Université de Montréal (CHUM). Her academic focus concerns the interface of ethical and epistemological issues in psychiatric practice. She is currently working on the epistemology of clinical reasoning in psychiatry. Notes 1. https://www.legisquebec.gouv.qc.ca/en/document/cs/s-32.0001. 2. https://laws-lois.justice.gc.ca/eng/annualstatutes/2016_3/fulltext.html. 3. https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel...

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