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From “Delete Your Account” to “Delete Yourself”: Legislated Suicide and the Role of Psychiatry

From “Delete Your Account” to “Delete Yourself”: Legislated Suicide and the Role of Psychiatry

© LASSEDESIGNEN/SHUTTERSTOCK.COM© LASSEDESIGNEN/ Shutterstock.com
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRISTSIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST

Although the election of Donald Trump on November 8, 2016, garnered the most intense attention nationally and globally, other noteworthy election results occurred that day. Specifically, Colorado became the latest state to legalize physician-assisted suicide (PAS) for terminally ill, competent adults. PAS is also variously called, depending on one’s perspective on the matter, “Physician Assisted Dying,” “Aid in Dying,” “Death With Dignity,” “Right to Die,” or simply “End of Life Option(s).”

By a 2:1 margin, Colorado voters passed the End of Life Options Act (Proposition 106), becoming the sixth state in which PAS is legal via a state law (Oregon, Washington, Vermont, and California) or through a court decision (Montana). Washington, DC, has also passed a “Death with Dignity Act,” and PAS legislation is making its way through state legislative processes in Hawaii, Maine, and numerous other states.

The Colorado legislature had previously considered aid in dying legislation on several occasions (1995, 1996, 2015, and 2016), but these legislative efforts were unsuccessful. Thus, the Colorado ballot initiative was a strategic success for aid in dying advocacy organizations. As described on one such organization’s website: “Compassion & Choices lent its policy know-how and deep understanding of aid-in-dying laws to work with petitioners to draft the proposed statute, while the Compassion & Choices Action Network provided important financial resources to foster an effective on-the-ground advocacy effort.”1 As in California, the legislation was modeled closely on the wording of the Oregon law. Of note, in California the law was passed during a special legislative session, and thus enacted without a vote by the general public.

Aid in dying and the role of psychiatrists

In every state where PAS has been or is being considered, proponents of PAS argue that there are adequate safeguards in place to protect patients who might be driven by mental illnesses such as depression to request PAS. However, when I talk to psychiatrists and non-psychiatrists alike, most people are surprised to learn that none of the current state statutes specifically mandate a mental health evaluation by a licensed psychiatrist or psychologist prior to the writing of a lethal prescription. Instead, the laws place the responsibility for determining the requesting patient’s decision-making capacity and mental health status on the “attending physician.”

In the words of California’s End of Life Option Act, “If there are indications of a mental disorder, the physician shall refer the individual for a mental health specialist assessment.”2 In other words, patients do not ever have to talk to a psychiatrist or psychologist unless their attending physician believes they should. This leads to an obvious, empirical question. In states where PAS is legal, how many patients who request and receive a prescription under the law have actually been referred to a mental health specialist for evaluation before receiving a prescription for the lethal drug? The answer: very few.

Oregon’s Death With Dignity Act (DWDA, enacted in 1997) requires the state to track a number of relevant statistics, and these reports are publicly available.3 Based on the 2015 report, which provides detailed annual data and summarizes cumulative data from 1998 through 2015, out of a total of 991 patients who died by ingesting the prescribed DWDA medication, 52 (5.3%) were referred for psychiatric or psychological evaluation. In 2015, 218 prescriptions were written (by a total of 106 physicians). Of those who received prescriptions in 2015, only 5 were referred for psychiatric or psychological evaluation. The patients’ “end-of-life concerns” (ie, reasons why they sought a lethal prescription) are also summarized in the report.

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