From the Editor
It may soon be the law… but is it ethical?
In 2016, Parliament passed Bill C-14, legalizing doctor-assisted suicide. The legislation represents a major change in many ways: from public policy to the practice of medicine. And, in the coming years, it’s quite possible that the scope of this legislation will be expanded, and could include those with mental illness.
In this week’s Reading, Dr. Wayne (Sandy) Simpson of CAMH weighs in on the ethics of medical assistance in dying (MAiD) and mental illness in this provocative “perspective” paper just published by The Canadian Journal of Psychiatry. He considers the nature of mental illness before concluding: “[A]cting as a partner in helping people recover as well as acting as an agent in a patient’s death is an impossible burden that is not ethically justifiable or legally necessary.”
Also, this week, we consider another recent paper by The Canadian Journal of Psychiatry that considers the impact of exercise on cognition in patients with depression.
MAiD and Mental Illness
“Perspective: Medical Assistance in Dying and Mental Health: A Legal, Ethical, and Clinical Analysis”
Alexander I. F. Simpson
The Canadian Journal of Psychiatry, 7 December 2017 Online First
In February 2015, the Supreme Court of Canada struck down the Criminal Code prohibition on physician-assisted suicide under certain circumstances. The federal government passed Bill C-14, which was enacted on June 17, 2016. Bill C-14 provides the legal structure for what has now been called medical assistance in dying, or MAiD, embracing both physician-assisted suicide (where the doctor prescribes medication for the person to take at some future time) and voluntary euthanasia (where the doctor administers medication to cause death). The cases before the Supreme Court were ones of terminal illness and severe disabling physical illness. The Court ruled that persons facing grievous and irremediable suffering on the basis of a serious medical condition (one of the index cases was a terminal condition and one a degenerative neurological disorder) should be able to seek MAiD. The Court’s decision did not limit the scope of MAiD to terminal illness, however, but left the door open for a number of other medical conditions and concerns to qualify for MAiD. The Court also found that persons whose condition is so disabling that they are unable to exercise their own right to end their own life have a right to seek assistance to do so. The Joint Parliamentary Committee recommended including nonterminal disorders, but Bill C-14 restricts MAiD to situations where death is ‘reasonably foreseeable’. This places MAiD largely in the area of end-of-life decision making, were MAiD is provided to a person whose death is ‘reasonably foreseeable’. Parliament further required independent review of whether the legislation should in future be extended to requests where mental illness is the sole underlying medical condition, consultation for which is currently under way.
MAiD has been quickly adopted. For the time period from June 2016 to June 2017 inclusive, 1981 persons have died using medical assistance, all bar 5 by voluntary euthanasia with 95.7% by physician and 4.3% by nurse practitioner.
The purpose of this article is to consider the issue of whether serious mental illness might be a condition that would allow a person to seek MAiD. The approach taken is to examine the fundamental ethical and clinical issues involved. For almost all situations where serious mental illness is the sole qualifying disorder, death is not reasonably foreseeable, nor is the person’s physical state so disabled that he or she is unable to exercise the right to end his or her own life.
He notes the potential for an interpretation under section 7 of the Charter:
The specific cases before the Supreme Court in Carter did not require a ruling in relation to ‘psychiatric disorders’. However, in deciding that the appellants’ charter rights were violated by the prohibition on assisted suicide, the Court noted that section 7 of the charter protects the right to make fundamental personal choices free from state interference. This included a notion of personal autonomy involving control over one’s bodily integrity.
Considering the implications, Dr. Simpson has hesitation:
The proposal to extend MAiD to include someone with a serious mental illness who retains the physical and mental ability to end his or her own life and who is not dying takes MAiD into a different ethical and constitutional framework than argued in Carter.
Status of Mental Illness
He notes the differences between mental illness and terminal illness:
Mental illness is not, generally, a terminal disease. Mental illness alone does not, generally, deprive people of their own ability to end their life. Suffering from a mental illness can be immensely difficult and painful. It can be life threatening. But the possibility of recovery is never lost.
Depression can lead a person to feel hopeless, worthless, and unable to change his or her life situation. Psychosis can grossly distort the nature of how the person experiences the world and people in it.
The Ethical Nature of a Request for Assistance to End One’s Life
Accepting MAiD for mental illness risks that despite our values of protecting and upholding life, we will also do the opposite and end life in some situations. Defining those situations is essentially one of individual value judgements by each psychiatrist about which lives are worth living and which are not. Will we progressively expand our definition of what life no longer has purpose or value? And are we sufficiently confident that we have the ability to do this, cognizant of the involvement of psychiatry in the eugenics movements of the past? What does it say to others who may be vulnerable and struggle to find meaning of a life with suffering?
The author goes on to conclude:
Those of us who work in mental health are only too aware of our limitations. There are people for whom it seems all we can do is inadequate to help them find a way to live. We need to be humble in the face of that limitation and keep striving to improve our care and practice. To introduce MAiD as an ‘option’ in this great struggle will only undermine our ability to help people who are suffering greatly with mental illness and burden clinicians with profoundly difficult ethical conflicts between hope, life, and assisted suicide. People may choose to take their own lives; that is understood and respected. But acting as a partner in helping people recover as well as acting as an agent in a patient’s death is an impossible burden that is not ethically justifiable or legally necessary.
MAiD should be confined to terminal illnesses and situations where a person is physically incapable of enacting his or her own wish to commit suicide and not to serious mental illness alone.
A few thoughts:
- This is a well-argued paper.
- Some of you will strongly agree with Dr. Simpson’s arguments; others will not. Remember: Readings are meant to spark debate and discussion.
- Past Readings have concerned the implications of Carter v. Canada. In an earlier Reading, we looked at the paper by Kim et al., which studied the Dutch experience. You can find it here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-doctor-assisted-suicide-the-dutch-experience/.
- Several organizations have weighed in on this topic, from CAMH to the American Psychiatric Association. So too have patients. In 2016, The Globe and Mail ran two thoughtful essays on opposing sides of this issue written by patients. You can find the pieces here:
Exercise and Cognition
“Exercise for Cognitive Symptoms in Depression: A Systematic Review of Interventional Studies”
Meng Sun, Krista Lanctot, Nathan Herrmann, and Damien Gallagher
The Canadian Journal of Psychiatry, 29 November 2017 Online First
This is a short but interesting paper. Let’s provide a short but interesting summary.
The authors open by noting the strong connection between depression and cognitive change:
Depression is frequently complicated by cognitive impairment and, although cognitive performance may improve marginally with treatments for depression, cognitive dysfunction usually persists and is associated with increased risk of persistent depression. Cognitive dysfunction is more closely associated with long-term functional outcomes than resolution of depressive symptoms, and is also associated with resistance to antidepressant treatment.
They then note the desire for an intervention:
Interventions that improve underlying cognitive dysfunction could potentially modify the longitudinal course of depression with improved functional outcomes and potentially reduced resistance to treatment.
Could exercise help?
Exercise has been used to treat depression and is known to have cognitive benefits in the general population, with one early pivotal study showing that adults who walk on a daily basis have reduced risk of cognitive decline.
They then drew from the literature. More specifically:
- The authors did a search of major databases, including Pubmed, looking for studies “where an exercise intervention was clearly described and its impact on cognitive function measured.”
- They identified 12 controlled studies, and 3 uncontrolled studies.
- Meta-analyses were done to calculate the effect, and to look at a variety of factors, like age, type of exercise and intensity of exercise.
- “No significant effect of exercise was found on global cognition (Hedges’ g = 0.08,P = 0.33, I2 = 0%) or on individual cognitive domains.” See figure below.
- “Interventions combining physical with cognitive activity significantly improved global cognition (P = 0.048), whereas low-intensity interventions were also positive (P = 0.048).”
In this meta-analysis, we failed to find a significant effect of physical exercise either on global cognition or on individual cognitive domains in study participants with depression. The impact was not influenced by the age of participants, baseline cognition, or the time spent exercising. However, interventions that combined physical exercise with cognitive activity significantly improved global cognition, and we also report positive findings for low-intensity interventions.
A few thoughts:
- This is a good paper.
- They ask a practical question: how to address cognitive issues in depression?
- Did they find a solution? Maybe. The combination of physical exercise and cognitive activity seemed to make a difference. It should also be pointed out that the approach is low intensity – meaning that it requires little but probably does help.
- Two quick questions – How often do you recommend physical exercise to your patients who have depression? How often do you recommend physical exercise plus cognitive activity to your patients who have depression?
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.