Medical Assistance in Dying for the Mentally Ill as a Cause Area for Negative Utilitarians
(Note: It’s a coincidence that this was posted on April Fool’s Day. I’m 100% serious.)
This is a short, not very well-thought-out post meant to be a starting point of conversation that I might eventually develop into something more substantial.
My main question here is: Should EAs who care about reducing suffering try to expand MAID for the mentally ill? And if so, what would that look like?
This question is personal to me. I’ve struggled with treatment-resistant depression and suicidal ideation all my life. I’ve attempted to take my life about 20 times. I’ve tried many (though not all) treatment options available on the market for depression. I’ve spent almost half of my life with 6 different therapists, I’ve been on 10 different meds, I’ve been hospitalized 8 times, and I’ve been through residential treatment, partial hospitalization, and intensive outpatient. And if I’m being honest, things have only gotten worse through all of this (heck, because of all of this). My mental health has lost me jobs and friends and all the other things that make life worth living. I could go on, but I don’t mean for this to be a pity post—just to make the point that for some people, like myself, I just genuinely think it does not and will not get better. It just seems, rationally, pretty unlikely that something I’ve dealt with for this long will just magically go away some day. I’d assign a 2% chance to going a month without active suicidal thoughts at any point in my lifetime (assuming an average lifespan).
I’d like to see a societal shift to a culture where it’s acceptable for at least some people to kill themselves. I’m not sure where the line should be—should you have to try certain treatments first, like ketamine or ECT? Wait a pre-set amount of time, say 1 year? Get a medical opinion that you are truly beyond help? That’s where I’d like to hear other people’s opinions. But for me the status quo—forcing people to either live a life of suffering when there isn’t evidence that it’ll get better, or to resort to painful methods to die—seems unacceptable.
A quick ITN analysis:
Importance/Scale: I think a project focusing on MAID for the Mentally Ill would probably first want to focus on getting better numbers regarding scale. According to this article, about 2.8 million people in the US have Treatment-Resistant Depression, which comes out to around 1% of the population. Should all of these people be eligible for MAID? Probably not, and I doubt all or most of these people would even want MAID. A closer approximation of how many people this might affect could be the number of members on forums discussing suicide, which range from 40,000 for a more underground forum discussing specific suicide methodologies (which I won’t name here but you can DM me for more info) and 470,000 for the Reddit forum r/SuicideWatch. These are of course funky numbers because they (a) only reflect a fraction of the people who are thinking about suicide and (b) again, not everyone would probably want or be eligible for MAID, but it’s my best attempt at attaching a number to this. Another big question affecting scale is how much worse a life of severe treatment-resistant depression is than death, which is bound to be subjective.
Tractability: Canada is currently set to introduce MAID for the mentally ill in 2027. I think but am not 100% sure that they are the only country to do this currently, but given it’s been done once, it should be feasible to do it again.
Neglectedness: A lot of what I’m aware of being done in this space focuses on educating people on reliable, peaceful ways to end their lives rather than advocating for wider accessibility for safe methods. (e.g. Exit International) Most of these most reliable and pain-free methods are insanely inaccessible though (and most of the most accessible methods are not reliable or peaceful). There seem to be some nonprofits advocating for Death with Dignity widely too. I might try to do a fuller scoping of the space in the future.
As you might imagine I am very biased about this issue so would love to hear counterpoints. Also, if anyone is open to collaborating on (or, dare I ask, funding?) a project regarding this, feel free to message me privately.
As you mention, the scale seems small here relative to the huge political lift necessary to get something like MAID passed in the USA. I don’t know much about MAID or how it was passed in Canada, but I’m picturing that in the USA this would become a significant culture-war issue at least 10% as big as the pro-life-vs-pro-choice wars over abortion rights. If EA decided to spearhead this movement, I fear it would risk permanently politicizing the entire EA movement, ruining a lot of great work that is getting done in other cause areas. (Maybe in some European countries this kind of law would be an easier sell?)
If I was a negative utilitarian, besides focusing on longtermist S-risks, I would probably be most attracted to campaigns like this one to try and cure the suffering of cluster-headaches patients. This seems like a much more robustly-positive intervention (ie, regular utilitarians would like it too), much less politically dangerous, for a potentially similar-ish (???) reduction in suffering (idk how many people suffer cluster headaches versus how many people would use MAID who wouldn’t otherwise kill themselves, and idk how to compare the suffering of cluster headaches to that of depression).
In terms of addressing depression specifically, I’d think that you could get more QALYs per dollar (even from a fully negative-utilitarian perspective) by doing stuff like:
funding Strongminds-style mental health charities in LMIC (and other semi-boring public-health-policy stuff that reduces depression on a population level, including interventions like “get people to exercise more”, or “put lithium in the drinking water”, or whatever)
literally just trying to use genetic engineering to end all suffering
using AI to try and discover amazing new classes of antidepressants (actually, big pharma is probably already on the case, so EA doesn’t have to take this on)
trying to find various ways to lower the birthrate, and especially of disproportionately lowering the birthrate of people likely to have miserable lives (ie children likely to grow up impovershed / mentally ill / etc), or perhaps improving future people’s mental health via IVF polygenic selection for low neuroticism and low depression.
Finally, I would have a lot of questions about the exact theory of impact here and the exact pros/cons of enacting a MAID-style law in more places. From afar (I don’t know much about suicide methods), it seems like there are plenty of reasonably accessible ways that a determined person could end their life. So, for the most part, a MAID law wouldn’t be enabling the option of suicide for people who previously couldn’t possibly commit suicide in any way—it’s more like it would be doing some combination of 1. making suicide logistically easier / more convenient, and 2. making suicide more societally acceptable. This seems dicier to me, since I’d be worried about causing a lot of collateral damage / getting a lot of adverse selection—who exactly are the kinds of people who would suicide if it was marginally more societally acceptable, but wouldn’t suicide otherwise?
Thanks for the comment!
I agree with this strongly—I initially put at the end of this post that I think most of this work should be done outside of EA spaces for the sake of the movement’s reputation but deleted that part for reasons I can’t fully remember.
I also agree with this—I think if I were to pursue this as a project it would be a matter of going after low(er)-hanging fruits in the more liberal countries of Europe to normalize it a bit and then bringing it to bigger/more difficult countries. Similar to the approach that is currently being taken for approval voting, drug legalization, etc. I’m not sure if it would ever pass in the US, at least not in my lifetime, though if it were available to non-citizens elsewhere (also a big lift) that could be a way around that.
I think more research is needed on this, absolutely. One thing I also didn’t mention is that we discussed this in an ethics class I took for my master’s degree and I believe some author had speculated that the added bureaucracy of going through this sort of approval process might actually force people to reflect on their life in a way that they wouldn’t if they resorted to more accessible means. And there may be other psychological impacts of it that we don’t fully understand, e.g. it could also be opening up the conversation/gateway to more intensive treatment methods that people might otherwise be afraid to access for fear of being locked up in a psych ward.
It looks like it’s already available in the Netherlands, Belgium, Luxembourg and Switzerland.
I guess the obvious approach would be to target jurisdictions where MAID is legal, but not just for mental illness. However, in the US, at least, it could be better to push for MAID excluding mental illness to other states where it isn’t already legal first, to avoid political polarization. This is just speculation, though.
Good points!
FWIW depending on how long these have been available, this makes me think it’s less useful to pursue, since that would make it less neglected (albeit more tractable) and make me think that other countries are probably going to start adopting it soon anyway.
One key consideration for me is to what extent we think people who would choose to commit suicide, or people who have lived with a long treatment-resistant depression, are likely to recover and live a worthwhile life (and to what extent suicidal individuals can predict their future well-being).
The academic literature seems very lacking here. I found a couple of recent papers:
https://www.sciencedirect.com/science/article/abs/pii/S0005789421000228 (a 2021 review)
https://digitalcommons.usf.edu/cgi/viewcontent.cgi?article=10503&context=etd (a 2022 master’s thesis on the topic, studying a cohort of 8,000 US veterans within which 400 had attempted suicide). It seems pessimistic, at a glance.
Thanks! I share this concern to some extent. Anecdotally I’ve heard of a whole lot of stories of people who attempted or came near attempting to take their life and then are glad they didn’t later on. I think the opposite happens a lot too but doesn’t get shared as much because of the stigma around suicide. “Local suicidal man says he’d attempt again” just doesn’t make for a great news story.
This also rests on an assumption (that I haven’t decided that I agree with) that it’s worse for people to potentially miss out on a future possibility of a good life than it is for them to certainly suffer with whatever is so bad they think it makes life not worth living, if that makes sense. It feels somewhat paternalistic to me, but I can see the merits of it also.