Mental Illness and Voluntary Euthanasia

 

 Canada’s House of Commons has passed a bill which would allow to euthanasia for people suffering from mental illness and a terminal condition, see Bioedge . Let us assume that anyone suffering a great deal of pain and who only is expected to have only short time left to live has a right to assisted suicide provided that she can give competent consent. Let us now consider Andy and Sandra. Andy who has no mental health has an incurable illness from which he suffers greatly. Andy should have a right to assisted suicide. Sandra who has the same illness as Andy and suffers just as much also has mental health problems. It would seem to be unfair to deny Sandra the same right as Andy to end her suffering. What reason could be given to justify this apparent unfairness? It might be suggested that Andy is competent to give consent whilst Sandra isn’t. Let us accept the idea of informed consent is based on respect for autonomy, some might question this assumption, see the doctrine of informed consent and respect for autonomy . Accepting the above might mean the cases of Andy and Sandra differ because Andy can give competent consent to voluntary euthanasia whilst Sandra can’t because Andy is autonomous and Sandra isn’t. If we accept the above it would appear unfortunately that we must accept Sandra’s suffering. I now want to argue that we should permit voluntary euthanasia for some people suffering from terminal illness who also suffer from mental illness. I will accept that only autonomous persons can make a competent decision to accept voluntary euthanasia.

What do we mean by an autonomous decision? Autonomous decisions are decisions we govern ourselves by. What does autonomy in practice? Let us consider a substantive account of autonomy. According to such an account an autonomous decision isn’t simply one the agent freely makes and doesn’t harm others. Let us label such an account as a primitive account. According to a substantive account an agent can only make an autonomous decision if he fully understands any information relevant to his decision and then makes a rational decision based on his best interests. Moreover the substantive element of this account means his best interests are not simply his subjective best interests but must concur with some norms or objective list. If we accept such an account then it seems likely that most mentally ill people wouldn’t be competent enough to consent to voluntary euthanasia and as a result shouldn’t be offered the option. However if we accept a substantive account of autonomy then the substantive element means autonomous decisions must be good decisions. I now want to argue against accepting such a substantive account of autonomy. If autonomous decisions must be a good decisions because they must concur with some accepted norms then it might be questioned whether such an account of autonomy is really doing any useful work. A substantive account of autonomy puts itself out of business because we only need to consider good and bad decisions. We don’t need to consider autonomous decisions at all. Some concerned with medical ethics might be happy to accept the above because they attach great importance to acting beneficently. Do we value autonomy because it helps us make good decisions? I would suggest we don’t. I would suggest that we value autonomy because we value persons. We value being the sort of creatures that can make their own decisions. We don’t respect autonomy because it helps us make good decisions we respect autonomy because respect persons. Respecting persons requires that we accept their decisions and this includes bad decisions. It follows that respect for autonomy means we should accept a non-substantive account. It might be objected that we can respect someone’s autonomy by respecting most of her decisions, but not all, and this means we don’t need to accept a non-substantive account. In response I would point out respect isn’t a part time concept.

Let us accept that that we should permit voluntary euthanasia for persons suffering from terminal who are able to give competent consent. Let us also accept that any autonomous decision using a non-substantive account of autonomy should be regarded as a competent one. What might a non-substantive account of autonomy look like? A random or coerced decision isn’t an autonomous one. An autonomous decision might have no substantive element but the way it is made matters. Autonomy is connected to persons and a person, distinct from a human being, is defined by what he cares about. I would suggest what we care about must have some persistence. (1) It follows that not all freely made decisions are autonomous ones. I would also suggest what we care about depends simply on what we will rather that what it would rational for us to care about, if this wasn’t so we would be returning to a substantive account of autonomy.

What are the implications of adopting the above non-substantive account of autonomy for the mentally ill? Let us accept that mental illnesses differ. For the purpose of this posting I will assume that they can be split into two main types. Mental illnesses which induce mood swings and mental illnesses which cause delusional beliefs. I will consider the effects of both types on someone’s ability to make an autonomous decision.

First let us consider someone whose mental illness means she experiences large mood swings. Such mood swings mean that she has difficulty in making persistent decisions, making autonomous decisions. It follows she has difficulty in making competent decisions. It follows if someone’s mental illness leads to large mood swings that she shouldn’t be offered the option of voluntary euthanasia. The same conclusion cannot be so easily reached if someone’s mental illness leads to delusional beliefs. Her decisions even if they are based on these beliefs might have persistence, reflect her will and if so should be regarded as autonomous and hence competent. At this point it might be objected that it would be absurd to accept as competent any decision based on a delusional belief. In response I would point out that this occurs in medical practice now. Consider a Jehovah’s Witness who needs a blood transfusion without which she will die. She believes that if she permits the transfusion that she will not be admitted to heaven. Because of this belief she refuses the blood transfusion. Her decision would be regarded as a competent one under existing guidelines. However to most people including me such a belief is a delusional one. It seem that in practice a decision based on a delusional belief might be regarded as a competent one. Perhaps then if someone suffering from mental illness makes a persistent decision based on delusion his decision should be regarded as a competent one. Perhaps also someone whose mental illness causes delusions might be competent enough to agree to voluntary euthanasia.

It might be objected that whilst some people have long standing delusions which help define them as persons such as the Jehovah’s Witness. My objector might then point that some people suffering from mental illness might be treated for their mental illness causing them to lose their delusional beliefs. Their delusional beliefs don’t define them as persons. I accept my objectors point but might in turn point out for someone suffering from a terminal illness time is limited and a change in her delusions is unlikely. Someone with a limited expected life span who suffers from long term delusions might be partly defined as a person by her delusions. If such a person has a terminal illness she might well to able to make an autonomous, competent, decision to accept voluntary euthanasia and should be offered the option. My objector might raise another objection to the above. She might suggest that my division of mental illnesses into two main types is flawed. She might point out depression doesn’t fit easily into either type. Once again I am prepared to accept her point. If depression can be quickly cured then someone’s depression doesn’t play a part in defining her as a person. Someone suffering from short term depression might not be able to make competent decisions and should not be offered voluntary euthanasia. However some depression is deep seated and play a part in defining someone as a person. This might be especially true for someone suffering from a terminal illness with a limited expected life span. Someone suffering from a terminal illness with deep depression might well to able to make an autonomous, competent, decision to accept voluntary euthanasia and should be offered the option.

What conclusions can be drawn from the above? First that applied philosophy can be a messy business and that mental illness is a broad concept. It follows not all of those suffering from a terminal disease and mental illness should have the option of voluntary euthanasia.  However those who can make an autonomous decision should. The above highlights the difficulties legislators, such as those in Canada, face when drawing up laws covering voluntary euthanasia. Lastly the concept of autonomy employed should be a non-substantive one.

1.  Harry Frankfurt, 1988, The Importance of What We Care About, Cambridge University Press, page114.