First, Do No Harm
by Omar Bassiouni
Image source: Unsplash
CL is a 24-year-old woman who comes into your office reporting worsening fatigue, hopelessness, chronic sadness, and guilt for the past several months. You first saw her at eighteen and later diagnosed her with Major Depressive Disorder due to similar feelings which started when she was a teenager. At that time, she confided that she grew up in a troubled household. The first time she was drunk was at four years old because her dad “thought it would be funny”. Her father was also verbally abusive to the rest of the family. Additionally, he and her mother would argue frequently in front of CL and her little brother. At sixteen, her father went to jail and her mother was left alone to raise the children. Two years later CL left her mother’s house and moved in with her boyfriend. He, like her father, has been verbally abusive and has difficulty accepting her diagnosis of depression, telling her to just “suck it up.” At this visit CL tells you that her new medication just isn’t helping. She says: “Nothing ever seems to work. I’ve been trying to get over my depression for years and this is the third medicine you have given me. I’m tired of fighting this.” CL then asks for your approval for physician-assisted suicide.
CL is fictional, but her story is an amalgam of real details from patients I’ve seen during my time shadowing, volunteering, and as an emergency department scribe. Unfortunately, her story, which is rife with adverse childhood experiences (ACEs), is more common than we may like to believe. The CDC writes on their violence prevention website: “About 61% of adults surveyed across 25 states reported they had experienced at least one type of ACE before age 18, and nearly 1 in 6 reported they had experienced four or more types of ACEs” (CDC, 2022).
I wrote about CL in response to the newly proposed expansion to the MAID law in Canada. MAID stands for “Medical Assistance in Dying”, a law that was first passed in June 2016 to allow eligible Canadians access to physician-assisted suicide. In March of 2021, the law was revised in response to a decision from the Superior Court of Quebec which found the “reasonable foreseeability of natural death” and the “end of life” eligibility criteria to be unconstitutional. In March of 2024, the law will be further expanded to allow MAID to people whose only medical condition is psychiatric in nature. The Canadian government has a webpage explaining the proposed MAID expansion saying: “Canadians whose only medical condition is a mental illness, and who otherwise meet all eligibility criteria, will not be eligible for MAID until March 17, 2023. This includes conditions that are primarily within the domain of psychiatry, such as depression and personality disorders”. Following legislation to extend the exclusion of people whose sole ailment is a mental illness, the eligibility date was moved to March 17, 2024. (The Canadian Department of Justice, 2023).
Consider the story of CL and how people struggling with depression, abuse, grief, and stigma will be affected by this law. What are the implications for the healthcare system if patients can elect suicide over other interventions? There are multiple ethical issues at play here. Will the patient-doctor relationship suffer if patients feel as if a physician had a hand in their loved one’s death? Will a rise in the popularity of suicide cause a social contagion, which will unnecessarily increase suicide rates? (Sonja A. Swanson, 2013) Can patients who are severely depressed give informed consent about ending their own life? How will this law affect the decision-making of patients with high-cost chronic or mental illnesses? Ultimately, we must decide: What is the role of the physician?
Sources
CDC. (2022, April 6). Fast Facts: Preventing Adverse Childhood Experiences. Retrieved from CDC.gov: https://www.cdc.gov/violenceprevention/aces/fastfact.html
Sonja A. Swanson, S. a. (2013). The Contagion of Suicidal Behavior. Canadian Medical Association Journal, 870-877. doi:10.1503/cmaj.121377
The Canadian Department of Justice. (2023, March 3). Canada’s new medical assistance in dying (MAID) law. Retrieved from Canada.ca: https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html
Omar Bassiouni is a third-year medical student at the UTCOMLS.
