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Cited by 61Ethics and bioethics in healthcareHealthcare Decision-Making and RestraintsHealth, Medicine and Society

“For Their Own Good”: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) where Mental Illness Is the Sole Underlying Condition

Open access
Dembo, Justine, Schuklenk, Udo, Reggler, Jonathan·2018·The Canadian Journal of Psychiatry
DOI 10.1177/0706743718766055PMC PMC6099778
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Abstract

Canada is approaching its federal government’s review of whether patients should be eligible for medical assistance in dying (MAID) where mental illness is the sole underlying medical condition, and when “natural death” is not “reasonably foreseeable”. For those opposed, arguments involve the following themes: capacity, value of life, vulnerability, stigma, irremediability, and the role of physicians. It has also been suggested that those who are able-bodied should have to kill themselves, even though suicide may be painful, lonely, and violent. Opponents of MAID for severe, refractory suffering due to mental illness imply that it is acceptable to remove agency from such patients on paternalistic grounds. After years of efforts to destigmatise mental illness, these kinds of arguments effectively declare all patients with mental illness, regardless of capacity, unable to make considered choices for themselves. The current paper argues that decisions about capacity must be made on an individual-patient basis. Given the rightful importance granted to respect for patient autonomy in liberal democracies, the wholesale removal of agency advocated by opponents of a permissive MAID regime is difficult to reconcile with Canadian constitutional values.

AI snapshot

Written from the paper’s full text.

TL;DR

This commentary argues against blanket exclusion of patients with mental illness as the sole underlying condition from MAID, contending that decisional capacity must be assessed individually and that strong paternalism/vulnerability rhetoric unjustifiably removes agency. It reviews Canadian legal context and cited evidence on capacity, irremediability, suffering, and suicide rates to support a permissive MAID regime with safeguards.

Key findings

  • Capacity must be assessed on an individual basis. The authors cite McCAT-T-based studies finding that 70% to 80% of involuntarily hospitalised patients with mental illness are capable with respect to treatment decisions; by diagnosis, only 4% of patients with a personality disorder lacked decisional capacity, whereas 80% of patients with acute psychosis due to schizophrenia lacked capacity, and among those with severe unipolar depression only 31% lacked capacity. They note these were acute inpatient studies and outpatients likely have higher capacity rates, though studies are lacking.
  • Mental illness can be irremediable. The authors cite STAR*D: 30% or more of patients did not respond to multiple sequential medication trials, and of those who did respond, up to 70% relapsed within 1 year. They also cite response rates of 55% to 64% for ECT, 29% for TMS in a meta-analysis, 48% at 6 months and 29% at 12 months for deep brain stimulation, and about 50% for ablative capsulotomy.
  • Suicide-rate concerns are not supported by cited data. Lowe and Downie’s analysis of OECD statistics for non-assisted suicide in Switzerland, Belgium, the Netherlands, and Luxembourg found that overall suicide rates either stayed the same or decreased after MAID legislation pertaining to sole mental illness was passed; a 2014 Swiss government report showed the suicide rate per 100,000 decreased steadily since before the legislation.
  • The authors argue that suffering in severe mental illness can equal that of severe physical conditions, citing a Berlin subjective wellbeing study in which only end-stage liver disease was subjectively as severe as mental disorders. They contend that “vulnerability” rhetoric stereotypes all psychiatric patients, removes agency from capable patients, and is difficult to reconcile with Canadian constitutional values and respect for autonomy.

Methods

  • This is a commentary/argument paper, not an empirical study; it reports no new sample, trial, or primary quantitative analysis.
  • It reviews ethical and legal arguments and Canadian MAID law and cases, including Carter v Canada, Bill C-14, and Canada v EF, alongside cited empirical literature on capacity, treatment resistance, suffering, and suicide rates.
  • The main analysis is normative/ethical: it distinguishes weak/soft paternalism from strong paternalism and argues that strong paternalism against competent psychiatric patients is unjustified in a liberal democracy.

Limitations

  • The paper states no limitations section.
  • Evident from the text: it is a normative commentary/response rather than a systematic review or empirical study; no systematic search strategy or formal quality appraisal is reported, and the cited evidence is used selectively to support the authors’ argument.
  • Evident from the text: conflicts of interest are declared—Dembo and Reggler report unpaid roles with Dying With Dignity Canada and/or MAID assessor organizations, while Schuklenk reports no conflicts of interest.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1177/0706743718766055

Cites

27 of 27 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 28 cited sources checked · 0 supported · 0 flagged

  • Findingcitation
    § Abstract

    Among those with severe unipolar depression, in this same study, only 31% lacked capacity.

    “Among those with severe unipolar depression, in this same study, only 31% lacked capacity.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] 18. Owen GS, Richardson G, David AS, et al. Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ (Clinical Research ed.). 2008;337:a448. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • Findingcitation
    § Abstract

    Data from jurisdictions where MAID is available to populations where death is not reasonably foreseeable do not show an increase in suicide rates.

    “Data from jurisdictions where MAID is available to these populations do not show an increase in suicide rates.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] 12. Lowe MP, Downie J. Does legalization of medical assistance in dying affect rates of non-assisted suicide? J Ethics Mental Health. 2017;10 http://www.jemh.ca/issues/v9/documents/JEMH%20final%20Legislation-iii.pdf. Published May 25, 2017. Accessed January 30, 2018.

      Not checked in the free run.

  • Findingcitation
    § Abstract

    In a large study of subjective wellbeing in Berlin, only end-stage liver disease was subjectively as severe as mental disorders.

    “For example, in a large study of subjective wellbeing in Berlin, the authors found only end-stage liver disease (a devastating and imminently lethal condition which only liver transplantation can reverse) was subjectively as severe as mental disorders.22”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] 22. Bernheim JL, Theuns P, Mazaheri M, et al. The potential of anamnestic comparative self-assessment (acsa) to reduce bias in the measurement of subjective well-being. J Happiness Stud. 2006;7(2):227–250. [Google Scholar] source

      Not checked in the free run.

  • Findingcitation
    § Abstract

    Lowe and Downie found that overall suicide rates either stayed the same or decreased after MAID legislation pertaining to sole mental illness was passed in Switzerland, Belgium, the Netherlands, and Luxembourg.

    “Lowe and Downie analysed OECD (Organization for Economic Cooperation and Development)14 statistics for non-assisted suicide in Switzerland, Belgium, the Netherlands, and Luxembourg. They found that overall, suicide rates either stayed the same or decreased after MAID legislation pertaining to sole mental illness was passed in those jurisdictions.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [12] 12. Lowe MP, Downie J. Does legalization of medical assistance in dying affect rates of non-assisted suicide? J Ethics Mental Health. 2017;10 http://www.jemh.ca/issues/v9/documents/JEMH%20final%20Legislation-iii.pdf. Published May 25, 2017. Accessed January 30, 2018.

      Not checked in the free run.

    • cites [14] 14. OECD Data. 2016. Suicide rates. https://data.oecd.org/healthstat/suicide-rates.htm. Accessed March 10, 2018.

      Not checked in the free run.

  • Findingcitation
    § Abstract

    A 2014 Swiss government report shows that the suicide rate per 100,000 individuals has decreased steadily since before the introduction of this legislation.

    “A 2014 Swiss government report shows that the suicide rate per 100,000 individuals has decreased steadily since before the introduction of this legislation.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] 15. Actualités OFS. Statistique des causes de décès 2014: Suicide assiste et suicide en Suisse. Département Federal de L’intérieur DFI, Office Féderal de la Statistiques OFS; 2014. https://www.npgrsp.ch/fileadmin/npgrsp/Themen/Fachthemen/BFS_2016_Suizide_Faktenblatt_f.pdf. Accessed March 10, 2018. [Google Scholar]

      Not checked in the free run.

  • May combine two claims. 9
  • Classified as probably not a substantial claim. 8

  • May combine two claims.

    Findingcitation
    § Abstract

    Another study using the McCAT-T indicated that only 4% of patients with a personality disorder lacked decisional capacity, whereas 80% of patients with acute psychosis due to schizophrenia lacked capacity.

    “By diagnosis, capacity can vary; another study using the McCAT-T indicated that only 4% of patients with a personality disorder lacked decisional capacity, whereas 80% of patients with acute psychosis due to schizophrenia lacked capacity.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] 18. Owen GS, Richardson G, David AS, et al. Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ (Clinical Research ed.). 2008;337:a448. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § Abstract

    In the STAR*D study, 30% or more of patients did not respond to multiple sequential medication trials, and of those who did respond, up to 70% relapsed within 1 year.

    “In the case of major depression, the STAR*D study conducted by the National Institute of Mental Health (NIMH), indicated that 30% or more of patients did not respond to multiple sequential medication trials, and of those who did respond, up to 70% relapsed within 1 y.31”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [31] 31. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer- term outcomes in depressed outpatients requiring one or several treatment steps: a STAR * D report. Am J Psychiatry. 2006;163(11):1905–1917. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § Abstract

    Mental suffering can frequently cause severe disability and premature death from medical illness and suicide.

    “Mental suffering can frequently cause severe disability and premature death from medical illness and suicide.23”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] 23. World Health Organization. Information Sheet: Premature Death Among People with Severe Mental Disorders. 2014. http://www.who.int/mental_health/management/info_sheet.pdf. Accessed March 10, 2018.

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § Abstract

    Neurostimulatory treatments such as ECT, TMS, or deep brain stimulation can be effective to some extent, but none are 100% effective.

    “Patients who fail repeated medication trials, hospitalisation, and psychotherapy sometimes go on to try neurostimulatory treatments, such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), or deep brain stimulation, all of which can be effective to some extent; but none are 100% effective.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [32] 32. Kellner CH, Knapp R, Husain MM, et al. Bifrontal, bitemporal, and right unilateral electrode placement in ECT: a randomized trial. Br J Psychiatry. 2010;196(3):226–234. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

    • cites [33] 33. Berlim MT, Van den Eynde F, Tovar-Perdomo Z, Daskalakis ZJ. Response, remission and drop-out rates following repetitive transcranial magnetic stimulation (TMS) for treating major depression: A systematic review and meta-analysis of randomized, double-blind and sham-controlled trials. Psychol Med. 2014;44(2):225–239. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

    • cites [34] 34. Lozano AM, Giaccobe P, Hamani C, et al. A multicenter pilot study of subcalossal cingulate area deep brain stimulation for treatment-resistant depression. J Neurosurg. 2012;116(2):315–322. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning
    § Abstract

    Judgments about suffering, irremediability, and quality of life are closely intertwined, and capable patients rightly define these terms as they apply to their own unique situations.

    “Judgments about suffering, irremediability, and quality of life are closely intertwined, and capable patients rightly define these terms as they apply to their own unique situations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Abstract

    Canadian courts recognise that suffering in mental illness can be unbearable; in Canada vs. EF, the Alberta Court of Appeal granted MAID due to severe pain and disability arising from a conversion disorder.

    “Canadian courts recognise that suffering in mental illness can be unbearable; in the case of Canada vs. EF (plaintiff),25 the Alberta Court of Appeal granted MAID due to severe pain and disability arising from a conversion disorder.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] 25. Canada v EF, 2016 ABCA 155.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationreasoning
    § Abstract

    Outpatients likely have higher rates of capacity with respect to treatment than acute inpatients, though studies in this area are lacking.

    “Of note, the above studies evaluated acute inpatients; outpatients likely have higher rates of capacity with respect to treatment, though studies in this area are lacking.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning
    § Abstract

    It is unjust to apply different standards to capable people with true refractory mental illness.

    “It is unjust to apply different standards to capable people with true refractory mental illness.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Respect for patient autonomy is a core value in liberal democracies and in Canadian constitutional values.

  • May combine two claims.

    Interpretationcitation
    § Abstract

    Because the SCC criteria neither excluded mental illness nor required a reasonably foreseeable death, government would need to show that including mental illness would increase the suicide rate, but existing evidence does not support this.

    “Because the SCC criteria neither excluded mental illness nor required a reasonably foreseeable death, government would need to show that including mental illness would increase the suicide rate, but existing evidence does not support this.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Abstract

    Bioethicists are highly critical of the vagueness of the label "vulnerable" and its propensity to stereotype groups of quite diverse patients.

    “Bioethicists are highly critical of the vagueness of the label and its propensity to stereotype groups of quite diverse patients.37”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] 37. Levine C, Faden R, Grady C, et al. The limitations of “vulnerability” as a protection for human research participants. Am J Bioeth. 2003;4(3):44–49. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation
    § Abstract

    Because suffering is a personal experience, only the affected individuals can assess whether it is intolerable.

    “Because suffering is a personal experience, only the affected individuals can assess whether it is intolerable.20,21”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [20] 20. Cassell E. Diagnosing suffering: a perspective. Ann Intern Med. 1999;131(7):531–534. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

    • cites [21] 21. Berghmans R, Widdershoven G, Widdershoven-Heerding I. Physician-assisted suicide in psychiatry and loss of hope. Intl J Law Psychiatry. 2013;36(5-6):436–443. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation
    § Abstract

    The Carter decision was clear that "irremediable" does not only refer to the statistical probability of survival with an illness but also to enduring physical or psychological suffering that is intolerable to the individual and that cannot be relieved under conditions that they consider acceptable.

    “The Carter decision was clear that “irremediable” does not only refer to the statistical probability of survival with an illness but also to “enduring physical or psychological suffering that is intolerable to [the individual] and that cannot be relieved under conditions that they consider acceptable.”36”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [36] 36. S.C. 2016, c.3.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning
    § Conclusion

    The MAID debate now highlights where strong paternalistic values persist in psychiatry.

    “The MAID debate now highlights where strong paternalistic values persist in psychiatry.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given
    § Abstract

    MAID is available to able-bodied, non-psychiatric, eligible patients.

    “MAID is available to able-bodied, non-psychiatric, eligible patients.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning
    § Conclusion

    It is unjustifiable to exclude psychiatric patients from benefitting from a medical intervention that is designed to preserve autonomy and reduce suffering, without giving due consideration to individual variability.

    “It is unjustifiable to exclude psychiatric patients from benefitting from a medical intervention that is designed to preserve autonomy and reduce suffering, without giving due consideration to individual variability.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Respect for patient autonomy is a core value in liberal democracies and in Canadian constitutional values.
    • Rests on an assumption: MAID is a medical intervention designed to preserve autonomy and reduce suffering.
15 of 15

  • The paper relies on this without support.

    Mental illness can unduly influence a desire to die.

    “given that mental illness can unduly influence a desire to die”

  • The paper relies on this without support.

    Respect for patient autonomy is a core value in liberal democracies and in Canadian constitutional values.

    “Given the rightful importance granted to respect for patient autonomy in liberal democracies, the wholesale removal of agency advocated by opponents of a permissive MAID regime is difficult to reconcile with Canadian constitutional values.”

  • The paper relies on this without support.

    MAID is a medical intervention designed to preserve autonomy and reduce suffering.

    “It is unjustifiable to exclude psychiatric patients from benefitting from a medical intervention that is designed to preserve autonomy and reduce suffering, without giving due consideration to individual variability.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The lack of response to these needs can prevent people living with mental disorders from having a satisfactory quality of life.

    “The lack of response to these needs can prevent them from having a satisfactory quality of life [31].”

    From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [31]

    The “Suffering, Irremediability, and Autonomy” passage (indexed as Abstract; page unavailable) links mental illness, suffering, and quality of life, and says severe mental illness can involve intolerable suffering. It does not identify unmet needs or say that a lack of response to those needs prevents a satisfactory quality of life. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • There is a small but growing literature on 'palliative' mental health care that asserts the need to recognize that current treatments, acceptable to the person, will still leave the person suffering and that as with some physical illnesses, recovery or cure is not obtainable.

    “Indeed, there is a small but growing literature on “palliative” mental health care that asserts the need to recognize that current treatments, acceptable to the person, will still leave the person suffering and, that as with some physical illnesses, recovery or cure is not obtainable (14).”

    From Medical Assistance in Dying: Challenges for Psychiatry (2018) · cites this paper as [14]

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Lemmens T, 2016, Les Grands Conflits en Droit de la Santé, 261
  2. Beauchamp T Paternalism. In: Jennings B. ed. Encyclopedia of Bioethics, 4th ed. Macmillan: Farmington Hill (Mich); 2014:2314–2321.
  3. Neilson G, 2015, Can J Psychiatry, 60, 1

Cited by

Sorted by citations

Related

Authors
Dembo, J., Schuklenk, U., & Reggler, J.
Affiliations
  • Sunnybrook Health Science Centre (CA)
  • Department of Philosophy, Watson Hall 309, Queen’s University, Kingston, ON, Canada
  • Courtenay Medical Associates, Courtenay, BC, Canada
Venue
The Canadian Journal of Psychiatry
Publisher
SAGE Publications
Published
2018-04-10
Volume
63
Issue
7
Pages
451-456
ISSN
  • 0706-7437 (ISSN-L)
  • 1497-0015
DOI
10.1177/0706743718766055
PMC
PMC6099778
OpenAlex
W2797345346
Semantic Scholar
389281181e84292e077169673f1a444e1f08d90d
Cited by
60
References
27
Citations by year
2026: 8 · 2025: 7 · 2024: 7 · 2023: 10 · 2022: 8 · 2021: 2 · 2020: 12 · 2019: 3 · 2018: 3
FWCI
4.76
Type
journal article
Language
en
Open access
Licence
journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations
  • The Canadian Journal of Psychiatry (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
  • Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
  • Health Sciences › Health Professions › General Health Professions › Health, Medicine and Society
Keywords
medical assistance in dying, mental illness, patient capacity, patient autonomy, paternalism, mental health stigma, natural death, reasonable foreseeability, value of life, vulnerability, physician role, euthanasia
MeSH terms
Adult, Mental Disorders, Canada, Ethics, Medical, Euthanasia, Humans, Legislation, Medical, Mental Competency, Suicide, Assisted, Persons with Psychiatric Disorders

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