7.8 Focus on Psychological Research – Psychological Distress Associated with MAID Requests

Most jurisdictions that have legalized MAID have required psychological evaluations in order to determine that the individual is “of sound mind” and relatively free of “psychiatric illness”.  While it is less controversial and easier to assess impairments in cognition that might accompany conditions like Alzheimer’s Disease or schizophrenia – conditions that compromise understanding of medical procedures and reality – symptoms like depression and anxiety create a murkier dilemma.  How much anxiety and depression is appropriate given the imminent end of life and how would we know if it is “excessive”, “pathological”, and “compromising fully informed consent”?  If we exclude individuals with significant anxiety/depression from eligibility for hastened death, is this a good thing because we’re preventing maladaptive decision making and impulsive decision-making? Or is it a bad thing because individuals with mental health concerns are deprived of equality, bodily autonomy, and autonomous decision-making?  Do delays in MAID authorization due to emotional distress allow for mental healthcare that can prolong quality of life – or do they needlessly protract suffering?  These questions are not easy to answer and will be central considerations in debates about MAID for years to come. Still, it can be worthwhile to study and understand how common emotional distress is among those who are terminally ill. The study below attempts to shed light on these issues.

Psychiatric Distress Among MAID Requesters

A study of 155 terminally ill individuals who had requested MAID in Canada were evaluated for the presence of a number of psychiatric symptoms and diagnoses (Isenberg-Grzeda, Nolen, Selby & Bean, 2021).  Approximately 39% of these individuals had psychiatric diagnoses in combination with their terminal health condition.  Unsurprisingly, the most common diagnosis was depression (accounting for nearly three-fourths of psychiatric diagnoses – and over one-fourth of all individuals requesting MAID). Anxiety disorders accounted for a full third of diagnoses seen in MAID requesters. Only 8% of psychiatric diagnoses were not anxiety or depression and only 6.5% of the total sample had been diagnosed with a serious mental illness (e.g., schizophrenia).  In sum, diagnostic level psychiatric illness is nearly as common as not among MAID requesters and the overwhelming majority of those cases are characterized by the types of distress one would well expect from terminal illness – i.e., anxiety and depression.  It is clear that in this particular Canadian care setting that simply having a psychiatric diagnosis does not render one ineligible for MAID, because 39% of the sample had such a condition but only 9% of the total sample were denied requests for MAID.  So nearly a third of all individuals requesting MAID had a psychiatric disorder and had their MAID requests approved. This figure will likely differ quite a bit based on country/culture, specific legal parameters, and provider.  One potential cause for concern in this study is the fact that less than half of those with a psychiatric condition who requested MAID had received psychiatric care – though it is not clear whether this was due to an institutional failure to provide such care of patients not accepting care that may have been available and offered.

As has been noted before in this text, it is important to be aware of and consider methodological issues that might have implications for the interpretation of a study.  What we know depends very much on how we know it.  This study relied on reviewing patients charts and medical records as opposed to doing complete and thorough evaluations with each patient as part of the investigation.  How might this impact findings?  One very likely impact is that the psychiatric comorbidity rates described above are arguably conservative and the rates may well be higher.  Why? It is more likely that a patient would not seek psychiatric care or acknowledge psychiatric distress to a medical provider – even if they were experiencing it – than it is that a provider would make a psychiatric diagnosis for a patient with little to no psychiatric distress.