Teaching about euthanasia for mental disorders and suicide prevention.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Canadian Medical Education Journal has published an editorial by Marcel F D’Eon, Mark S Komrad, Jeremy Bannon called: Teaching suicide prevention: a Canadian medical education conundrum. The article focuses on the medical education curriculum and the tension around suicide prevention and Medical Assistance in Dying (MAiD) also known as euthanasia, for patients with mental disorders. The editorial asks the question:

What are we educators to do when we find ourselves needing to teach about MAiD for mentally ill patients alongside suicide prevention and what we might consider for MAiD in general?

The editor writes:

At White Coat Warm (the) Art (International Congress on Academic Medicine, 2024), I was struck by the artwork and accompanying text by Nicole Graziano (University of Alberta) published in this issue of the CMEJ. Nicole’s art poignantly depicts what she called “the torment, grief, and freedom of suicide.” The white noose portrayed over a backdrop of light and dark sheds small white flowers filling the space. Her enigmatic set of words on its own caused me to pause. For me, her art juxtaposed the tragedy of suicide, liberation, and the expansion of MAiD, especially for those with psychiatric disorders. How does one help students and residents grasp the need to prevent suicide while offering MAiD to the psychiatrically ill?

The editor then examines the word suicide in relation to MAiD. He quotes Dr John Maher who stated:

Dr. John Maher, editor of the Journal of Ethics in Mental Health, has also pointed this out. How are educators then, supposed to teach students to provide suicide prevention to some patients who exhibit “self-directed behaviour with an intent to die” and simultaneously assist patients who request MAiD thus also demonstrating “self-directed behaviour with an intent to die”? Learners will notice this incongruence and have questions. We need to help them find some resolution.

The editor points out that there are a wide range of views concerning the issue of MAiD and how it may apply to people with psychiatric conditions. The editor then writes:

For a broad discussion of this topic, we could also explain the history of human rights in Canada and around the world where Canada was considered a pioneer and model for other countries. But here too there are controversy and opposition: the United Nations’ Special Rapporteur on the rights of persons with disabilities; Independent Expert on the enjoyment of all human rights by older persons; and Special Rapporteur on extreme poverty and human rights declared that MAID in Canada was not consistent with human rights. We need to acknowledge this wide range of local and international opinions on MAiD, including relevant rulings by the Supreme Court of Canada, and allow our learners to discuss these openly and transparently without repercussions.

The editor then deals with the question of autonomy:

First, that there are no choices that are completely and wholly autonomous. We all live in a context with intertwining relationships and limitations where our decisions are made, at least in part, after consideration of what is possible and desirable within our unique situations. Our teaching about the social determinants of health affirms this perspective. Patients with mental disorders face longer waits for care, have less access to state-of-the-art expertise in certain conditions, and are generally far less economically resourced then people with other illnesses. How could these circumstance not shape the  MAiD decision?

Second, autonomy is an instrumental value. Autonomy helps us lead a fuller, better life, one of our choosing. Self Determination Theory posits that autonomy supports two other major motivators in our lives. Namely, it helps us make a world of our choosing and to enhance our sense of both accomplishment and belonging. Looking back, we reflect and learn from what we ourselves have chosen, good and not so good. But the exercise of autonomy in the MAiD decision does not lead to a fuller life, and we do not get to live with an enhanced sense of accomplishment or belonging. For those who chose MAiD, they cannot ever say of their MAiD choice, the one facilitated by medical professionals, “I’m proud of what I’ve done” and hence their exercise of autonomy was for naught.

The editor completes the article by stating that there is a diversity of thought on these issues. One of the concerns in the Canadian culture is an attitude that "shuts down the debate" and imposes a point of view on the culture.

Marcel D'eon - professor Emeritus, University of Saskatchewan, Canada; Dr Mark Komrad - Faculty of Psychiatry, Johns Hopkins and University of Maryland, USA; and Jeremy Bannon - Assistant Clinical Professor (Adjunct), Michael G. DeGroote School of Medicine, McMaster University, Ontario, Canada. Correspondence to: Marcel D’Eon, email: marcel.deon@usask.ca