Suicidal ideation is very common for people with bipolar disorder. As are suicide attempts and successful suicides. I'm bipolar and I grapple with suicidal ideation. As part of my intensive therapy, and with proper meds, I've learned tools that help me deal with the suicidal ideation. But it's a brutal struggle sometimes. So does Canada mean to allow bipolar people to commit suicide? At any adult age? That saddens and angers me. My suicidal ideation is a temporary symptom of my mental illness. I spend more time in euthymia than in either manic or depressed states. But will Canada allow bipolar people to kill themselves when they're experiencing the recklessness and despondency that comes with mood episodes? When their decision-making is so compromised? This feels distinctly unhealthy and immoral.

Expand full comment

This article and concept is extremely relevant to our family, or rather, it was last year. My 16 year old grandson was in unbearable and increasing pain, and no one could find the cause or any method to ease the pain. He went to several of the best hospitals in the Northeast of the US, then his parents began to look further afield and at alternatives. He was taken to Arkansas to a clinic for Complex Regional Pain Syndrome, which did not succeed in any way in lessening the pain or in finding and curing the cause, because, as it turned out, it was not CRPS. A couple of fascinating and dedicated doctors in Louisiana and Texas did some extraordinary work with him using frequencies, which had some effect, but his condition continued to worsen despite a slight diminution of the pain. The most powerful effect was the love and focus of prayer that he received in the treatments in hospitals and clinics in the South. But his pain was unrelenting- and no amount of morphine or any other drugs made it bearable. He had lost the ability to ingest any nutrients, even by IV, for at least a month before he died. Family friends researched and could not find any place at that time where a minor could legally be the recipient of euthanasia.

In fact, though the family and the boy considered that this would be appropriate, even given the situation, no one was ready to make that happen. Right up until the end he continued to live, to love, to be present. I don't know at what point he would have been administered a death-giving cocktail were it legal- it's a situation frankly too awful to contemplate now. As he gradually lost fifty pounds - he died weighing about 70 lbs- the level of pain was unbearable, yet no one knew what to do. No one had anything to offer. No one wants to let someone so loved to die, but to allow someone suffer like that is not conscionable. There are times when there are no good solutions, only accommodations to suffering. I will never be a campaigner for assisted suicide. As another comment states, it's too easy for temporary states of depression or illness to be taken as signs that a life should end. As for my grandson's life, every day, suffering or not, was precious. There was no way out but onward. I'm trying to imagine what it would have been like for his father, his mother, his other grandmother, his brother, his cousins, his aunts and uncles and friends- all of whom came to see him in Louisiana, if someone had offered him death, in a cup. Maybe if that were a commonly recognized option we could have handled it. He spoke of it often, saying he'd like to die- but without the bitterness or rage that would have made it seem like the best, albeit cruelly withheld, option.

Expand full comment

Mill wrote and modern liberalism holds that when carefully regulated a state must respect the personal autonomy of each individual self with respect to personal decisions that affect only the person herself.

The state ought not impose life decisions , including the right to die, on the rational individual that are contrary to their own autonomous choice and agency just because in the state’s judgment the state is a better judge of what is good for them.

Arraying an endless list of personal health disasters and then drawing an arbitrary line created by a legislature of what qualifies for euthanasia and what sorts of suffering do not qualify, is a fools errand.

What credentials could possibly qualify a politician to decide who can end their own suffering and who cannot? There are none. Indeed there is no collection of medical or legal experts together who have that competence to decide for the entire population in the general case and in advance who qualifies and who does not.

With respect to the victims of severe incurable mental illness, ponder this.

A person suffers intense paranoid schizophrenia with terrifying auditory and visual hallucinations. She has had adequate trials of the most powerful antipsychotic drugs and inpatient therapies. She fears the side effects of the drugs so much she stops them frequently and her terrors return. Her life consists of life on the streets resulting in frequent arrests. Medical science understands she will suffer from her illness for the rest of her life. Custodial institutional asylum care does not exist. She is 30 years old and has been szhizophrenic since age 18. Her only family is a physically disabled mother. Can she request euthanasia assisted by a physician? Who should decide?

Expand full comment

I want to disagree on a number of grounds.

First, you are correct that there will be more uncertainty as to whether the life will be worth living if the period is longer. But, as you also point out the potential downside is greater as well. It seems to me what should matter is the expectation not the variance in outcome. Forcing someone to live a life that's expected to be awful because you aren't sure it will be awful seems just as bad as forcing them to live a life that you know will be awful.

Second, I feel you make alot of controversial empirical assumptions in this analysis. Yes, other things being equal a longer period offers a greater chance the situation will change. But that's information available to both the doctor and person making the choice. Your argument depends on the idea that they won't take this factor into account. Given the behavior of most people with terminal illness I think, if anything, people tend to be overly optimistic about outcomes in the distant future and if that's the case the population you are excluding from access to assisted suicide may actually be have more reason to expect a negative future than those who you allow to access it.

Finally, I think you are making some controversial assumptions about how doctors and others are likely to respond to this freedom. Yes, I can imagine a few rogue doctors helping those with severe chronic depression end their lives but if anything most doctors are far too unwilling to even take risks to fix treatment resistent depression (I've had friends die bc when both time and safer treatments fail many doctors don't go to more extreme/risky treatments as they would for cancer).

Indeed, if you at least in theory allow euthanasia in these circumstances I think it's plausible that you bring depressed people into the medical system where I expect them to be directed to treatment in the usual case when they may we'll have simply opted to end their life on their own otherwise.

Ultimately, in the case of more long term conditions the individual generally has the option of ending their life themselves. While I agree that in the usual case that is a mistaken choice I tend to think bringing them into the medical system and forcing them to talk to doctors and therapists represents a better not worse outcome even on average no matter what you think about the tiny fraction of cases where they are actually helped to commit euthanasia.

Expand full comment

"Well, what makes life worth living?"

I guess, if we can, we might start asking the people living. My guess is we would get different answers.

"According to one perspective, which we may call the life-first perspective, there is no explanation of what makes life worth living. Living is intrinsically good, period."

According to one perspective we may call the death-first perspective, there is no explanation for what makes life worth living. Dying is intrinsically good, period. Don't share that perspective myself; kind of like your life-first perspective.

"We could also defend a third, compromise position, which says that life is worth living both intrinsically and also because of the good things it contains."

I honestly have no idea what you mean by "intrinsically". I think the word in this context is kind of intrinsically meaningless.

"If we think that life is worth living at least in part because of the happiness we experience, what should we say about pain and suffering? An obvious answer is that pain and suffering make life less worth living."

Yup, pretty obvious.

"Much can change over the course of that much time. They have ample opportunity to turn things around."

Yup, things *could* get better. And things could get worse.

"You might experience lingering physical pain, and the loss of capacity will always be an inconvenience. But you’ll adjust to your new situation. The pain will become less acute over time."

Or it could get worse. You are sounding quite omniscient now. I do hope it would get better though.

" If misery lessens over time, then a miserable person with decades left to live is probably not actually facing decades of misery. "

Well, sometimes misery increases over time or stays constant.

"The fact that unhappiness diminishes with time is a general observation, not an ironclad law."

*Sometimes* unhappiness -- or pain of various sorts -- increases over time or stays constant. This is I think an ironclaw law. It has been observed to be true in some cases, no? If the observation that happiness diminishes with time *in general* is true, what does that matter to specific cases? I guess, that can provide hope. How long should a person hope, while suffering?

"Everything seems intolerable, and nothing is acceptable. Under the new Canadian law, any advanced and irreversible illness or disability is one that you can seek euthanasia for, provided that you are depressed enough about it."

I don't think you have a very good understanding of "depression". A person believing that they are "enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable" is not necessarily depressed, in a like "brain illness" sort of way. Theoretically, a person who believes such a thing could have a very healthfully functioning brain such that were a physical condition for example, not present, they would be quite happy. Some people experiencing "depression" are in that state regardless of any obvious environmental factors. Deep sadness, despair, and hopelessness are not necessarily illnesses, but rather reasonable / "healthy" emotional states due to environmental conditions. In such situations, the "depression" is the effect of the pain a person is experiencing; and not a cause or the primary pain itself.

"But depression itself can be a temporary condition, particularly if that depression is brought on by the onset of some new medical condition. As we learn to adjust to the condition, depression can lift."

And -- sometimes people do not adjust. Some people, after a particular loss, life does not regain its meaning, ever. We know this, because people commit suicide following what they felt as severe losses. And when they do, they more so than not do so alone, and without the support of people around them.

" Consider again what your life would be like if you lost your leg in a car accident. This is both physically and psychologically traumatic. You would require extensive therapy, both physical and psychological, to recover. And perhaps you will never fully recover, but life will eventually become worth living again. "

I'd hope it did. But, really, I'd make a wager there are people in which this was not the case. A person was in a really bad car accident. They were severely injured in some way. And they felt their lives did not become worth living again, and they made the decision to end it.

"Yet, in the weeks following the accident, you might become depressed about your misfortune and try to end your life. Should you? If you can’t go through with it, should your doctor help? And if they did help, would that be an act of compassion?"

How about we change "weeks" to "years". What if, after years of pain and suffering that all our current medical technology cannot adequately relieve, a person no longer wishes to experiment with boundless hope. They kill themselves. Would it have been callous to be the person that *doesn't* assist them and rather condemns them to a horrific death that could even fail and make their condition worse? And what does that person who didn't assist or eternally discouraged them think of all those years the person suffered? Worth it? Perhaps we should ask the person who suffered and then chose to end their own life.

"But it’s hard—perhaps impossible—to know whether that is the case. We have good reason to think that happiness can recover over time, given adequate support."

Its perhaps impossible to know whether happiness will recover over time, regardless of the support.

"We ought to be trying to provide that support."

Definitely. As long as is "reasonable".

"If someone gets up on the ledge in their darkest hour, the compassionate course of action isn’t to give them a good, hard shove. It’s to talk them down."

What if someone is merely sitting on the couch, in their darkest month, year, or decade -- the compassionate course of action may be to give them a means to end that darkness earlier, peacefully, rather than later, maybe dreadfully.

"We can’t be reasonably confident that a long duration of life will contain much more pain and suffering than happiness. Therefore, there is no perspective from which euthanasia for someone with many years yet to live can be justified."

Your final conclusion is a non sequitur.

A more logical perspective: We can't always be reasonably confident that a long duration of life for any particular person who has been suffering will have more happiness sometime in the unknown future. Therefore, there is no perspective from which we should categorically and uncontextually restrict assisted euthanasia for someone with many years yet to live.

There was actually a time in my life in which I went through substantial physical and emotional suffering, and at that time I had made the decision that if my condition did not improve after a year, I'd no longer want to sustain that suffering. Fortunately, my condition did improve. But I still to this day think if it did not, it would have been the best decision for me to end my own life. It would have been compassionate, toward myself. I do not suspect a person who encourages someone to endure possibly endless extended suffering because of an unbounded belief that suffering could some time end in the future is doing so out of compassion for the individual suffering. I suspect it has more to do with their own fears of pain and the possibility of mortality--or if they love the person--avoidance of grief and possibly guilt--or if they have certain religious attachments, avoidance of guilt. Most are reasonable motives, but they shouldn't be wrapped in a veneer of morality.

As for the law -- I am skeptical we will find something perfect. But it certainly shouldn't be founded on your belief that suicide or euthanasia is never justified when a person still has potentially a large quantity of years remaining in their current round of life. That is more likely to be callous, than compassionate.

Expand full comment

There is a serious problem with assisted suicide in the case of the very ill or disabled wife (or husband). She (or he) may be persuaded to act in order to make life better for the spouse; not because the ill person really wants to die.

Expand full comment

Re: When Assisted Suicide Goes Too Far

The most obvious flaw in the article lies in the philosopher’s thinking that it is useful to define the problem as epistemological in a general sense rather than a problem of knowing what to do in in a particular case. The question “How can one know that suffering is permanent and happiness impossible?" is itself impossible to answer in general terms because the categories it examines – suffering and happiness – are made up of widely disparate instances of suffering and happiness.

Canadian law evolved in response to successive rulings on specific challenges under the Canadian Charter of Rights and Freedoms. In the first, the Supreme Court of Canada found “in the case of a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition … that causes enduring suffering … intolerable to the individual in the circumstances of his or her condition,” that the prohibition against physician-assisted death infringes on their right to life, liberty and security under the Canadian Charter of Rights and Freedoms. In response, the government passed a law that afforded this right only to persons whose death is reasonably foreseeable. Extending the right further came only in response to another case in which the court found that the previous bill was still contrary to rights of the person to life, liberty, security and to equality under the Canadian Charter.

There has been no “slippery slope” here. It has simply taken legislators some time to bring the law into compliance with the original findings of the court.

By basing itself on the rights of the person, Canadian Law recognizes and respects the fact that the important epistemological (or moral) standpoint in deciding what to do is that of the suffering person. The thorny problem of predicting the future in the face of suffering belongs primarily to that person and only secondarily to those around them, including the clinicians who may seek to help them. In each case, clinicians owe to the person to do what they reasonably can to help ease their suffering and to help them recognize the limits of what is knowable about their future. In each case the clinician must ensure that the person has capacity, that the request is voluntary and that they have a grievous and irremediable condition. In no case are clinicians obliged to act against their conscience.

The key point is that, because the law on assisted dying in Canada is based on the rights of the person, the epistemological problem belongs to the capable suffering person and not to a philosopher or policymaker taking a God’s eye view of the general problem of human suffering.

That most sufferers and most clinicians are aware of the limits of what they can or cannot know about the future is suggested by the relatively small number of completed assisted deaths for cases in which death is not considered reasonably foreseeable.

1. Carter v. Canada 2015: https://www.canlii.org/en/ca/scc/doc/2015/2015scc5/2015scc5.html

2. Bill C-14 2016: https://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent

3. Truchon c. Procureur général du Canada 2019: https://vlex.com/vid/truchon-v-procureur-general-819818681

4. Bill C-7 2020: https://justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html

Expand full comment

Here is a hypothetical situation for consideration. A man commits a heinous crime for which he is sentenced to life in prison. The man is remorseful, in fact, extremely depressed about the crime and is concerned that in the unlikely event he is ever released back into society, he will commit a similar crime.

Further, the man believes that a life in prison would not be worth living. Would the Canadian authorities allow euthanasia?

Expand full comment