This is not a typical essay on suicide. There is nothing typical about this story or the woman whom the story is about. For confidentiality reasons, identifying information has been altered and I will refer to her as Mrs. L.

Mrs. L was a 68-year-old woman admitted to hospital in Toronto, Canada, for pain secondary to a spinal cord tumor, which caused loss of bowel and bladder function and muscle weakness. She had been living with this condition for approximately 2 years, during which time, her symptoms had worsened. She was no longer able to ambulate, and by the time I first met her, was completely bed-bound.

Her pain was severe. The first day I met her, she grimaced in agony, her smooth skin folding into a thousand tiny wrinkles. She never cried out and wasn’t always in pain, but when the pain started, the loud, animated conversation would stop suddenly and leave in its place a tangible silence.

Her request to me was simple. “I want to die,” she said, “help me to die.”

As a psychiatry resident, these are words I hear far too often. The World Health Organization estimates that more than 700,000 people die by suicide each year, 4500 in Canada alone [1, 2]. In the USA, suicide is the 11th leading cause of death, and 48,183 Americans died by suicide in 2021 [3].

In my work, I am often asked to urgently assess individuals with suicidal ideation. During these encounters, I assess for a treatable mood or psychotic disorder to “cure” the suicidal ideation and prevent death by suicide.

In the case of Mrs. L, however, the story was different. I completed a full diagnostic assessment. Mrs. L was not clearly depressed and there was no evidence of psychosis. She had never experienced suicidal ideation up until her diagnosis. She cited the pain and the inability to ambulate as the primary reason to end her life.

Not only had Mrs. L never experienced suicidal ideation, but she had a fiery enthusiasm for life. She was a poet and master wordsmith who spoke in a compelling and intense way. Her hands would gesture in emphasis of her speech, and she had fuzzy salt-and-pepper hair, never quite combed back, which gave her the appearance of an eccentric, yet distinguished, professor.

While there was room for optimization of Mrs. L’s pain medication, her goal was medical assistance in dying (MAID). In Canada, MAID is a government-approved procedure in which a person with a serious and incurable illness may be found eligible to end their suffering by physician-assisted death. Eligibility requirements are strict and necessitate that a person be in an advanced state of irreversible decline and experience intolerable physical or mental suffering that cannot be alleviated under conditions the person considers acceptable [4].

I wondered if the current eligibility criteria truly applied to Mrs. L. She was certainly suffering, but in my opinion, she did not appear close to death and there was more that we could do to help.

I struggled with her request and continued to examine her capacity to make the decision for MAID. I asked her why she preferred to die instead of optimizing her pain control. She told me that she feared cognitive dulling, a potential side effect from strong pain medication. To Mrs. L, without her mind, there was no meaning to her life.

When I was told that Mrs. L was indeed eligible for MAID and would be undergoing the procedure later that week, I was unsettled. Was I wrong to think of her desire for MAID as suicidal ideation that needed to be treated?

I parted from Mrs. L the day before the MAID procedure with tears welling up in my eyes. “Take care,” I said, and she reached out to hold my gloved hand. I never saw her again.

The finality of Mrs. L’s death by MAID left me with more questions than answers. I felt sad, confused, and morally conflicted. Mrs. L never faltered in her confidence that this was the right decision for her, but I could not understand it.

I wondered about the responsibility of physicians in making life-and-death decisions, and how we can determine the extent of another’s suffering. Did Mrs. L’s decision to end her life qualify as “suicidal ideation?” If so, how could we have let Mrs. L go through with MAID when we try so hard to protect our patients from seeking death?

I have been trained to think of any request to die as another symptom of depression or other mental illness that can and needs to be cured. However, the story of Mrs. L made me think: When does suicidal ideation, with all its negative connotations, become an accepted MAID procedure in which doctors agree to help end another’s suffering in the most final of ways?

From a legislative perspective, the Canadian MAID law is more recently making headlines due to proposed changes which would allow for people with sole mental health issues to request MAID. A decision on this matter has been postponed until 2024 due to the ethical complexity of the issue [5].

I wonder what will happen if MAID becomes an option for those suffering with mental health conditions. How would we as practitioners who choose to guard life above all else, cope? When does the best care mean no longer trying new treatments but instead approving and aiding in death?

My conflicting feelings surrounding Mrs. L’s death remain, and this essay is an attempt to reflect on my experience with Mrs. L and honour her unique character. She prompted me to think deeply about the intricacies of our responsibility as physicians to do no harm. While I write perplexed about her death, what I remember clearly is her life. Ultimately, she lived in the same way she chose to die, with freedom, dignity, and a strong sense of meaning.