What Does “Irremediability” in Mental Illness Mean?

van Veen and colleagues’ review hones in on the pivotal issue of irremediability in the context of mental illnesses and medical assistance in dying (MAiD). ¹ While specific terminologies may vary, in every jurisdiction allowing MAiD, irremediable conditions serve as the entry point for MAiD. Three themes emerge from the review—uncertainty associated with predicting irremediability, the potential impact on hope of assessing irremediability, and the interaction of treatment refusal with irremediability. Important as each of these individual issues is, equally important is the implicit recognition that irremediability in mental illnesses is not a static, unipolar concept but rather reflects an interaction between multiple factors.

Regarding uncertainty of irremediability, van Veen and colleagues find a lack of consensus on whether or not irremediability can be predicted for mental illnesses. This is similarly reflected in other reviews, from CAMH stating that “(T)here is simply not enough evidence available…for clinicians to ascertain whether a particular individual has an irremediable mental illness” ² and the Expert Advisory Group on MAiD concluding that “determinations of irremediability and irreversible decline cannot be made for mental illnesses at this time,” ³ to the Halifax Group stating that “in specific cases, the eligibility criteria of enduring, intolerable and irremediable suffering, and advanced and irreversible decline in capability could be met.” ⁴ Notwithstanding these contrasting views, no standards for defining irremediability in mental illnesses actually exist. ⁵ Furthermore, as the Council of Canadian Academies (CCA) noted, “the issue is not whether there are people who have mental disorders that are irremediable, but rather whether clinicians can confidently determine whether a particular case is irremediable.” ⁶

van Veen and colleagues propose empirical research to diminish the level of uncertainty about irremediability, and deliberation on what level of certainty would be acceptable. In this complex ethical debate, a key question beyond just degree of uncertainty is: What is leading to that uncertainty? And perhaps more fundamentally: What is being determined as being irremediable? The literature van Veen and colleagues cite sometimes refers to irremediable conditions and at other times to irremediable suffering. These issues, while related, are far from interchangeable. We know that especially in mental illnesses, psychosocial factors significantly contribute to suffering. ⁷ Social isolation, poverty, inadequate housing, and under or unemployment compound suffering from mental illnesses, and many say the stigma and discrimination they experience is worse than the symptoms of the illness itself. ^8,9 Suffering from illness is not compartmentalized from other life suffering. Like the concept of “total pain” in palliative medicine, ¹⁰ it is total life suffering cumulatively that determines the tolerability, or intolerability, of suffering. As CCA expert panelists pointed out, “the most relevant issue with respect to incurability and MAID (for mental illness) is not whether treatment can cure a person’s mental disorder, but whether it can alleviate suffering and reduce the symptoms that are motivating their request for MAID.” ⁵

Complicating things further, unlike illnesses with reasonably well-understood pathophysiologies like cancer or spinal stenosis, we still lack fundamental understanding of the underlying pathophysiology and etiology of most mental illnesses. ¹¹ Considering this, would society consider a (any number)% chance of irremediability from advancing metastatic cancer to be the same as a (same number)% chance of irremediability of suffering from a clinical depression associated with significant loneliness and poverty? These hard questions need to be asked.

Reviewing arguments concerning potential interactions between hope and irremediability, van Veen and colleagues again find diverse views, from authors concluding that a label of irremediability risks fueling hopelessness to others believing that acknowledging irremediability can increase hope by providing empathic engagement and the possibility of ending suffering through MAiD. van Veen and colleagues rightly point out that “often hopelessness is seen as a state of mind, both for the patient and the doctor, not necessarily related to the actual prognosis,” and suggest more empirical research is needed on hope. In this regard, research is particularly lacking on the potential impact of provider hope in the context of MAiD. van Veen and colleagues cite opinions that “false hope” in providers could lead them to recommend “invasive and useless treatment(s).” The implication is that false hope, presumably fueled by a desire to themselves be useful and help the patient, prompts providers to pursue inappropriate interventions other than MAiD rather than considering MAiD as an option. A particular area of research warranting exploration is a more nuanced consideration of whether MAiD itself could be the intervention some providers turn to in response to the drivers of false hope. In other words, could empathic frustration and feeling powerless to help while witnessing patients’ continued sufferings, coupled with the desire to be useful, lead other providers to support MAiD as a way to feel helpful themselves?

Citing a study finding 8 of the 48 psychiatric patients granted MAiD did not pursue it since “simply having this option gave them enough peace of mind to continue living,” van Veen and colleagues indicate that for some, the option of MAiD could lead to recovery. This speaks to empathic engagement, a fundamental underpinning of most therapeutic frameworks. It also raises a headache inducing quandary reminiscent of Captain Kirk’s closed (il)logic loop from 1967’s Star Trek episode “I, Mudd,” ¹² by raising the challenging question of “If irremediability is required for eligibility for MAiD, how can being eligible for MAiD lead to remediability?” This harkens back to the question of what is being deemed irremediable, a medical disorder or a more complex state with multiple psychosocial levers.

Finally, van Veen and colleagues elegantly summarize the potential interplay between treatment refusal, irremediability, patient preferences, and clinical best practice recommendations. They rightly conclude informed policy-making requires both empirical data and normative considerations regarding physician–patient relationships. However, unlike the “balance” they cite in Dutch euthanasia law, Canadian law has no requirement that any reasonable alternatives be pursued prior to MAiD eligibility. van Veen and colleagues indicate Canadian MAiD policies consider “suffering is irremediable when all treatments acceptable to the patient have failed,” yet that implies some treatments have been tried. Uniquely in the world, Canada’s law only requires that patient suffering “cannot be relieved under conditions that they consider acceptable,” ¹³ without requiring that any reasonable alternatives have been pursued. As a CCA key finding recognized, “No other country permits MAID (for mental illness) where one of the eligibility criteria is based on an individual’s personal assessment of what conditions for relief of their intolerable suffering they consider acceptable. If Canada were to expand MAID (for mental illness) using this criterion, it could become the most permissive jurisdiction in the world with respect to how relief of suffering is evaluated.” ⁵

With MAiD policies across Canada and the world in flux, van Veen and colleagues’ review of irremediability is timely. These issues cannot simply be left for the courts to determine, they require key input from clinical professionals, evidence-based empirical guidance, and thoughtful consideration regarding what normative principles are acceptable. Legislators have themselves indicated they turn to medical associations and colleges for definitions of irremediability, and that such terms “do not require further statutory definition.” ¹⁴ Specifically regarding irremediability and mental illness, legislators have indicated they have “faith in the expertise of Canadian health care professionals to develop and apply appropriate guidelines for such cases.” ¹⁴ This is why, while van Veen and colleague’s contribution is welcome, the recent Canadian Psychiatric Association (CPA) Position Statement on MAiD is such a disappointment.

Beyond concerns that this Statement was developed by the CPA Professional Standards and Practice Committee without the awareness or engagement of CPA membership, external stakeholders or experts, or internal groups like the CPA Research Committee, the Statement itself is highly problematic. ¹⁵ The Statement mostly identifies generic principles that, while sound, provide no guidance on any of the many complex issues related to mental illnesses and MAiD. Strikingly for a national medical association, there are no references to any evidence related to mental health or illness. The Statement remains notably silent on how or whether irremediability can be assessed in mental illnesses, avoiding the issue entirely, while confusingly stating that “Patients with a psychiatric illness should not be discriminated against…and should have available the same options regarding MAiD as available to all patients.” Given the absence of any guidance regarding predicting irremediability, does this mean that it would be discriminatory to not provide MAiD to patients for mental illness, or that it would be discriminatory to provide such patients MAiD by exposing them to death based on unscientific determinations of unpredictable irremediability for which there are no standards? Senior CPA members, including former CPA Presidents (myself included), have called for the CPA to rescind the Statement and develop evidence-based recommendations using a proper engagement process. ¹⁶

van Veen and colleagues’ review highlights that the concept of irremediability of mental illnesses warrants nuanced and thoughtful consideration and is a dynamic issue influenced by varied interactions. If we wish to live up to legislator’s faith in the profession to develop appropriate guidelines, contributions such as van Veen and colleagues’ valuably help elucidate challenging issues that must be considered in this complex debate.