Tautology: A wish to die is suicidality?

Sisti et al (2024) [1] embrace some arguments about Medical Assistance in Dying. An argument that rages across the continents – especially where one looks at enabling it for conditions that are not terminal. However it ignores the broader physician assisted dying debate. Their argument that in a mood disorder ‘[Choosing MAiD] this decision marks another significant difference with medical MAID and psychiatric MAID. The former is a decision about how a patient wishes to die because of a terminal or irremediable condition, while the latter raises the question of whether a person wants to live at all.’ is a ‘selective abstraction’, in that conditions other than depression may be irremediable. Nor do they consider Benelux legal concepts of ‘unbearable suffering’. The very identification of treatment resistance and lifelong illness patterns speaks to the challenges of improving outcomes for patients with mental illness. Challenges about identifying or the meaning of treatment resistant/irremediable are well explored [2]

People with depressed mood can suffer from serious cognitive errors, but not all will. The Dutch experience suggests that fears of a wave of death are exaggerated, when few requests for PAD are approved on mental health grounds [3]

Putting this to one side, arguing for parity of mental and physical health but excluding access to PAD/MAiD ignores the great strides taken for civil rights embodied in the UNCRPD [4], which would require member states to avoid discriminating against mental illness. The very argument that the ill may not make decisions for themselves ignores the lived experience movement, and is ‘ableist’

The focus might better look at whether a decision is capacitous or not, rather than whether one agrees with the choice. Societal positions on assisted conception, termination of pregnancy, or gender issues, have changed dramatically over a half-century; plus ca change!

Of course societies may decide that PAD/MAiD is not acceptable for conditions for which there is no prospect of relief. A problem that has been around for Millenia – are we prolonging live or protracting death? In either event whilst we may all agree that those whose decision making is impaired should not be allowed to make this decision, there is not universal agreement on whether capacitous individuals who do not wish to continue living should be allowed to end their existence, with or without humane assistance.

1 https://doi.org/10.1136/jme-2023-109522
2 McIntyre RS, Alsuwaidan M, Baune BT et al. World Psychiatry 2023;22:394-412.
3 Snijdewind M, Willems D, Deliens L et al. JAMA Intern Med 2015;175:1633-40.
4 UN Department of Economic and Social Affairs. Convention on the rights of persons with disabilities (CRPD). https://social.desa.un.org.