Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS

Physician-assisted suicide (PAS) continues to be a hot topic, and has been addressed recently in 

. In discussing the topic, we last addressed the issue of “

 In the ensuing 3 years, 4 states—Hawaii, Maine, New Jersey, and New Mexico—have passed statutes permitting physicians to provide lethal drugs for patients who are terminally ill and wish to end their lives. One of us (Pies) recently testified before a legislative committee in Massachusetts, where a bill permitting PAS is now being considered.

 The pace at which a growing number of states are either passing or considering PAS legislation seemed compelling enough to warrant another look at what we call “the autonomy myth” in assisted suicide.

We previously argued that most PAS statutes:

provide nothing remotely resembling ‘autonomy’ for the patient, in either the procedural or personal sense. Patients who wish to avail themselves of prescribed, lethal medication must clear a number of procedural and administrative hurdles that depend entirely on the diagnostic, prognostic, and prescriptive authority of the patient’s physician. The controlling decisions regarding the patient’s diagnosis; the need for a consultant to confirm the diagnosis; the putative ‘terminal’ nature of the illness; the completion of required certification forms; and, finally, the writing of the lethal prescription are all exercises of the physician’s autonomy. 

Even refusals of a patient’s request for PAS reinforce the primary role of physician autonomy in these decisions. It is clear that, at any point in this sequence—ie, prior to dispensing of the lethal drugs—a simple act on the part of the patient’s physician could overturn the patient’s request for assisted suicide (personal communication from Annette L. Hanson, MD, October 16, 2021). In short, PAS provides no procedural autonomy for the candidate/patient. Rather, PAS legislation is an example of extreme heteronomy—ie, handing over power and authority to others.

In our prior commentary, we also pointed out that autonomy is only 1 of 4 cardinal medical values; the others include beneficence, nonmaleficence, and justice

 It has been primarily in the past 60-70 years—since the rise of the consumer movement—that autonomy has been enshrined as the primary, if not the sole, 

Furthermore, the overly individualistic and near absolutist concept of autonomy that reigns in Anglo-American law and bioethics is historically and culturally conditioned. There are many other types of autonomy than are dreamt of in our thin philosophy. Personal autonomy does not resonate with many cultural groups that perceive themselves as vulnerable or disenfranchised. Indeed, as we have discussed elsewhere, individual autonomy is subordinate to other significant ethical values in many other ethnic and cultural groups. For example, in many traditional 

 and Latino cultures, familial or community autonomy is far more important, particularly when end-of-life decisions are involved.

Although our earlier article cited the Georgetown Mantra of the ethical theory termed 

, there is a growing recognition that in many of its applications—such as in the justification of PAS—it is a thin, reductionistic schema of bioethics. It largely ignores older and arguably more substantive moral-ethical frameworks, such as the duty-based (deontological) morality developed by Immanuel Kant, or Aristotle’s virtue ethics. Some critics, drawing from a feminist perspective, have criticized the dominant conceptualization of autonomy for neglecting important relational and interpersonal values.

 Crucially, as Soren Holm, DrMed, PhD, has pointed out, the Georgetown principles evolved in an American context, and may not be fully transferable to other cultures and societies.

Finally, our previous article distinguished between genuine autonomy and pseudo-autonomy, and argued that current PAS statutes are generally not capable of assessing genuine autonomy. We noted that current PAS procedures do not systematically assess the patient’s 

—including the potentially coercive influences of those who might stand to gain emotionally or financially from the patient’s death. (The recently proposed PAS bill in Massachusetts—H.2381—ostensibly provides for assessment of coercion, but only at the time of clinical evaluation.

 To our knowledge, no law includes a mechanism for evaluating the authenticity of the patient’s autonomy just prior to their ingestion of the lethal drugs.) Nor do the superficial assessments of decision-making capacity required under various PAS statutes address subtle, but important factors that can compromise genuine autonomy, such as the patient’s unconscious fears and fantasies.

With that recap in mind, we now expand our discussion of genuine or rational autonomy and the closely related concept of authentic voluntarism as explicated by Laura Weiss Roberts, MD, MA.

Rational Autonomy: A Cognitive-Emotional Dyad

Rational autonomy is much more than being able to “do as you please.” After all, an infant picking up his rattle is doing as he pleases, but he is hardly acting with rational autonomy. The latter, in our view, consists of both a cognitive and an emotional component. Cognitively, rational autonomy requires, at a minimum, that the person understands the nature, risks, and benefits of the procedure or action under consideration, and has a basic understanding of the alternatives. This component is roughly what is implied in most definitions of “decision-making capacity.”

Rational autonomy is much more than being able to “do as you please.” After all, an infant picking up his rattle is doing as he pleases, but he is hardly acting with rational autonomy.

However, this minimalist criterion fails to capture the subtle cognitive distortions exhibited by some patients who are terminally ill. For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, have noted that some 

 may make erroneous assumptions like, “No one can help me,” or “No one understands what I am going through.”

 Such cognitive distortions can cloud the patient’s judgment and undermine rational autonomy. These distortions may respond favorably to cognitive behavioral interventions, which may avert or abort a request for PAS. (Importantly, no current PAS statutes require any form of psychotherapy for patients seeking to end their lives via PAS.) 

The emotive component of rational autonomy is more nuanced and complex, involving both an external and internal dimension. Thus, a patient facing the prospect of PAS may be feeling external pressure from family or significant others, either for or against the assisted suicide. The greater risk, of course, is when the patient is being pressured to agree to PAS, because that is a decision that irreversibly ends all other decisions on the patient’s part. Obviously, a decision regarding PAS cannot be called 

 under such coercive conditions. And to repeat: Once the patient leaves the evaluation milieu and obtains the lethal drugs, nothing in current PAS statutes ensures that the patient will be free from coercive pressures in the home or family setting.

Although external coercion is nominally addressed in some PAS statutes, what is not considered in any current PAS statute is the patient’s emotional, motivational, and psychological state, which may even more severely compromise rational autonomy. For example, in our previous article, we noted that a request for assisted suicide may mask deeper, underlying wishes or fantasies—eg, the request may be a covert plea for the physician to be more empathic about the patient’s situation, or amount to a test of whether the physician still values the patient’s life as death approaches.

Crucially, the evaluating physician typically has neither the training nor the tools to reliably and validly assess such complex and nuanced emotional states. Moreover, cognitively-based instruments such as the MacArthur Treatment Competence Assessment Tool do not delve into subtle emotional factors that may be affecting, if not clouding, the patient’s judgment.

Emotions such as hope, anger, joy, sadness, fear, and many others…often play a major role in health care decisions to consent to or refuse treatment, and consent or refusal of [PAS]…Yet at present there is no consensus or theoretical vision on how to incorporate such facts into the MacArthur model. Who decides whether hope is appropriate or not

Proponents of PAS claim that statutes require physicians to assess and treat conditions such as major depression that may impair the patient’s capacity to make a rational decision. Yet, even if patients who are terminally ill do not meet full DSM-5 criteria for a major depressive disorder, they may nevertheless feel hopeless, demoralized, or despairing.

 Or, patients may be experiencing anticipatory 

 over impending death; ambivalence regarding assisted suicide; or the fear that their loved ones, and even their physicians, will abandon them. Patients may soon come to view PAS, irrationally, as the only way out of loss, conflict, and isolation. These subtle emotional states may cloud judgment and undermine rational autonomy, yet will not be picked up by a brief, one-time, cognitively based assessment of decisional capacity.

Roberts has explicated a concept she calls 

, which has very strong affinities with our construct of rational autonomy. Roberts argues that voluntarism must be understood comprehensively, taking into account “developmental factors, illness-related considerations, psychological issues…cultural and religious values, and external features and pressures.”

 Each of the 4 domains Roberts identified is in some degree likely influencing the reasoning and emotions of the person seeking PAS.

Suffering and pain due to physical or mental health problems may cause one to move toward a decision out of desperation rather than deliberateness and adherence to personal values...[furthermore], some beliefs and psychological defenses that emerge in the process of dealing with an overwhelming illness may be a barrier to perceiving and considering alternatives.

Along with our colleagues, Mark Komrad, MD, and Annette L. Hanson, MD, we have argued that psychiatrists should not collude with competency determinations in the context of PAS evaluations.

assess the patient for evidence of depression, despair, hopelessness, or demoralization, as well as for subtle cognitive distortions threatening authentic autonomy and voluntarism. This need not entail a decision regarding competence to request or consent to PAS.

Furthermore, psychiatrists can recommend somatic treatments and/or supportive counseling, including cognitive remediation, for those individuals who are terminally ill and whose authentic voluntarism is in doubt. Indeed, evidence suggests that when physicians intervene and successfully address issues such as 

, depression, and other medical problems, as many as 46% of patients seeking assisted suicide will change their minds.

In a 2007 paper on voluntarism, Geppert and her colleague, Chris Abbott, MD, MD, sketched an outline of a voluntarism assessment and recommended that psychiatrists further develop more holistic and comprehensive evaluations of voluntarism. The same work needs to be done for the assessment of rational autonomy, following the guidelines Roberts suggested.

This essay has challenged the all-too-commonly held belief that PAS is an instantiation of a patient’s autonomy. In fact, we have argued the contrary: The entire process of PAS is critically dependent on the authority of powerful others who must approve (or veto) every decision along the way. Even more centrally, we have argued that genuine rational autonomy and authentic voluntarism are frequently undermined by subtle cognitive and emotional factors that are likely to be missed with standard, cognitively based evaluation tools. Patients who may not meet DSM-5 criteria for a mental disorder may nevertheless be experiencing hopelessness, demoralization, or despair—any of which can compromise rational autonomy and authentic voluntarism. In addition, current PAS statutes provide no mechanism for assessing external coercive influences that may drive the patient to suicide after having left the evaluation setting. In addition to the many ethical reasons to oppose PAS,

 psychiatrists should also be aware of the subtle cognitive and emotional issues that compromise rational autonomy in the context of terminal illness.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is also a health care ethicist with the Ethics Consultation Service of the Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College, and she serves as the ethics editor for 

1. Geppert CM, Pies RW. Two misleading myths regarding “Medical Aid in Dying.” 

https://www.psychiatrictimes.com/view/two-misleading-myths-regarding-medical-aid-dying

https://alexschadenberg.blogspot.com/search/label/Ronald%20Pies

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4. Pies RW. Physician-assisted suicide and the rise of the consumer movement. 

https://www.psychiatrictimes.com/view/physician-assisted-suicide-and-rise-consumer-movement

5. Geppert CM, Pies RW. Religious, and ethno-cultural competence in palliative and end-of-life care. 

OBM Integrative and Complementary Medicine. 

https://www.lidsen.com/journals/icm/icm-05-01-016

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https://academic.oup.com/jmp/article-abstract/26/4/365/900410?redirectedFrom=PDF

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8. An Act Relative to End of Life Options. Bill H.2381. 

9. Levin TT, Applebaum AJ. Acute cancer cognitive therapy. 

https://pubmed.ncbi.nlm.nih.gov/30555220/

10. Hicks MH. Physician-assisted suicide: A review of the literature concerning practical and clinical implications for UK doctors. 

https://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-7-39

11. Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: A clinical tool to assess patients' capacities to make treatment decisions. 

12. Charland L, Lemmens T, Wada K. Decision-making capacity to consent to medical assistance in dying for persons with mental disorders. 

https://www.researchgate.net/publication/303520825_Decision-Making_Capacity_to_Consent_to_Medical_Assitance_in_Dying_for_Persons_with_Mental_Disorders

13. Bower B. ‘Deaths of despair’ are rising. It’s time to define despair. 

https://www.sciencenews.org/article/deaths-of-despair-depression-mental-health-covid-19-pandemic

14. Roberts LW. Informed consent and the capacity for voluntarism. 

https://pubmed.ncbi.nlm.nih.gov/11986120/

15. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. 

https://www.psychiatrist.com/jcp/depression/suicide/assessing-competency-for-physician-assisted-suicide-is-unethical/

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https://pubmed.ncbi.nlm.nih.gov/10684915/

17. Geppert CM, Abbott C. Voluntarism in consultation psychiatry: The forgotten capacity. 

https://pubmed.ncbi.nlm.nih.gov/17329464/

18. Snyder Sulmasy L, Mueller PS, Ethics P, Human Rights Committee of the American College of P. Ethics and the legalization of physician-assisted suicide: An American College of Physicians Position Paper. 

https://pubmed.ncbi.nlm.nih.gov/28975242/

Articles

In cases of assisted suicide, do patients really have rational autonomy?

Physician-Assisted Suicide and the Autonomy Myth

We would like to respond to the article "

 Their article in turn addresses an earlier essay on 

Strouse et al place forms of actively hastening death under the rubric of medical aid in dying (MAID), noting that 10 states and the District of Columbia have now legalized MAID, and that “all current state laws explicitly stipulate that such deaths are not suicide.” Their letter argued for a distinction between decisions to “directly hasten one’s own death” in the context of terminal illness, and what they called “conventional suicides.” Citing work including a statement from the American Association of Suicidology (AAS), Strouse et al argued that suicide is not the same as physician aid in dying, and that—allowing for some overlap—the 2 acts differ on the level of psychopathology. They further suggested clinicians distinguish between conventional suicide and MAID, so that they may “work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.”

We respect Strouse and his colleagues’ clinical experience and humane intentions. However, as psychiatrists, medical ethicists and a palliative care physician (Dr Geppert), we find this thesis deeply troubling. In particular, the focus on state laws ignores the central ethical question of whether physicians’ helping patients kill themselves is ever justified in the context of terminal illness or in any other circumstance.

The notion that 22% of the US population live in a state where MAID is legal is a demographic fact, not a value claim. As Daniel P. Sulmasy, MD, has observed, “data cannot tell a society or a profession what ought to be done” and neither can legislation. This is a consequence of what philosophers call the 

. Sulmasy has said, “Whether just 1 person or 100,000 persons legally avail themselves of lethal prescriptions cannot tell us whether the practice is right or wrong.”

The mere fact that some state legislatures have passed statutes redefining suicide, such that MAID is not suicide, does not prove that this redefinition is conceptually or ethically justified; in fact, several judicial decisions have held this opinion. In 2017, the New York Court of Appeals held that “suicide has long been understood as ‘the act or an instance of taking one’s own life voluntarily and intentionally’ ... Aid-in-dying falls squarely within the ordinary meaning of the statutory prohibition on assisting a suicide.”

 Similarly, in 2016, the New Mexico Supreme Court held that the prohibition against assisted suicide unambiguously covered self-induced death in situations such as those described by Strouse et al.

 (521 US 702, 1997), the US Supreme Court permitted laws prohibiting assisted suicide because of the states’ compelling interest in suicide prevention, effectively equating assisted suicide with suicide.

While redefining suicide averts legal liability for physicians providing MAID, it does not change the essentially unethical nature of the act itself. The term 

 fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term 

 Perhaps even more significant, following a comprehensive evaluation by the Council on Ethical and Judicial Affairs, the American Medical Association (AMA) House of Delegates rejected the term 

 Indeed, the process typically described as MAID in no sense aids dying; on the contrary, it rapidly converts an ill individual into a dead one. This is substantively different than the withdrawal of heroic but nonbeneficial or inappropriate measures, such as the use of ventilators that merely prolong the dying process in the final stages of a terminal illness.

Finally, statutorily declaring that self-induced death via a physician’s assistance is not suicide may soothe the consciences of legislators and allow payouts on life insurance policies; but, perversely, it may also incentivize some terminally ill patients to kill themselves. Furthermore, as Sulmasy

 notes, preliminary reports suggest increased rates of suicide in the general population of states that have legalized PAS. Specifically, “legalizing PAS has been associated with an increased rate of total suicides relative to other [non-PAS] states, and no decrease in non-assisted suicides.”

 Similarly, suicide rates in the Netherlands (where medical euthanasia is legal) have accelerated, compared to neighboring countries that have not legalized medical euthanasia.

Redefining suicide to exclude PAS in the context of terminal illness represents a radical linguistic maneuver that flies in the face of ordinary language, expressed over thousands of years. The Latin 

from which the English word suicide is derived—means the act of killing oneself intentionally or voluntarily. To be clear: we do not deny that there are often psychological and motivational differences between those with terminal illnesses who take their own lives and those who do so in the context of severe psychiatric illness, as the AAS statement details. But in both instances, the act is that of suicide

[A] s a philosopher, I feel an obligation to point out that, as a conceptual matter, there is nothing inaccurate or false about stating that a person who takes a drug, knowing that it will cause her death, and takes it because it will cause her death, is committing suicide on any reasonable conceptual analysis of what suicide is.

The hijacking of ordinary language is becoming increasingly common, such that comforting euphemisms like 

 have replaced the more troubling ordinary language term 

 Accordingly, one might reasonably wonder if the insistence that MAID not be described as suicide betrays some cognitive dissonance regarding the practice, especially on the part of psychiatrists whose duty is to prevent suffering patients from taking their own lives. The 

of many physicians who carry out MAID has been well-documented.

Cognitive Distortions, but No Mandated Treatment

Furthermore, most MAID laws do not require treatment for serious medical conditions, even when it is available to the patient. For example, a patient whose metastatic cancer stands a reasonably good chance of remission with aggressive treatment, but who nevertheless 

, is not required by state laws to undergo the treatment.

 Choosing assisted suicide in such a scenario may superficially appear to be a rational choice; but may instead represent a decision grounded in certain cognitive distortions that also characterize so-called conventional suicide. Importantly, this may be so, even in the absence of a diagnosed psychiatric disorder.

For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, noted that some cancer patients may make erroneous assumptions, like, “No one can help me” or “No one understands what I am going through.”

 Such cognitive distortions may respond favorably to cognitive behavioral interventions and potentially avert or abort a request for PAS. Indeed, it has been found that “Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided.”

Unfortunately, in almost every US jurisdiction where PAS is allowed, no attempt to offer treatment by a mental health professional is required by law; and the psychiatrist’s role is typically relegated to ruling out mental illness and 

The Issue Is Not Intractable Pain and Suffering

As Daniel P. Sulmasy, MD, PhD, noted, “Despite public arguments that PAS is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control.”

 These are forms of psychological distress which, in our view, are best managed with supportive and empathic counseling and/or cognitive behavioral interventions, provided to patients and their families—not by prescribing lethal drugs. Indeed, as Levin and Applebaum pointed out

[T]he root of many patients’ desire for a hastened death may reside in dysfunctional thoughts such as, ‘I get claustrophobic in small spaces like coffins’ and ‘I deserve to die.’ Exploring such cognitions by asking, ‘What are your biggest fears about death and dying?’ will allow the cognitive therapist to reframe dysfunctional thoughts. For example, if the patient worries that death is always painful based his perception of his grandfather’s death in 1975, the therapist might explore how good pain management can facilitate a more peaceful death and contrast the state of palliative care in 1975 versus the advances of the present day.

Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories of physician aid in dying and conventional suicide.

 Accordingly, we believe that the same precautionary principle that governs public health ought to apply to MAID requests.

This means erring on the side of caution and treating MAID requests from patients with terminal illnesses with the same degree of psychiatric scrutiny and concern that we would bring to any patient’s expressed wish to die. However, in most states, psychiatric assessment is not mandated in the MAID process and does not occur unless specifically requested by the evaluating physician who has initiated the MAID process.. This rarely happens. For example, in Oregon in 2020, only 0.8% of patients who were 

 were referred for psychiatric evaluation.

Moreover, the fairly subtle cognitive distortions described by Levin and Applebaum are unlikely to be detected in a superficial assessment of mental competence. It is no contradiction or paradox to argue, as we have, that pronouncing a patient qualified or competent for MAID is a violation of psychiatric ethics, since this unethically colludes with the process of aiding a patient’s suicide. Psychiatric involvement in end-of-life care is indeed essential, but it should remain well outside the procedures and processes involved in MAID deliberations.

Reducing Stigma vs Shifting it to the Other

Strouse et al emphasized that, “Most importantly, they [MAID laws] are intended by lawmakers to help avoid the stigma of suicide.” we agree that there is societal stigma associated with suicide, as the AAS recognizes. This, the AAS asserts, is in contrast to attitudes surrounding physician aid in dying

: “Death by suicide is often associated with substantial social stigma... [whereas] where it is legal, PAD is typically well accepted within the community and society at large.”

We infer from their commentary that Strouse et al would agree with the AAS claim (and co-author Margaret Battin, PhD, is a signatory to the AAS statement). Although well-intentioned, the AAS position and that of Strouse et al may have the unintended effect of increasing stigma directed toward those who attempt or complete a non-MAID suicide. In our view, creating a binary distinction between MAID and conventional suicide tends to marginalize individuals in the conventional group as “the Other.” This position may suggest to the general public that suicidal individuals with mental illness value their lives less than those with terminal physical illnesses—a claim we reject.

Indeed, as numerous suicide prevention websites 

: “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.”

 We would suggest that the same may be said of at least some individuals with cancer who seek MAID. Whenever complex ethical dilemmas are formulated as black-and-white categories, the many grey instances are often misclassified, with tragic consequences.

In short, the AAS position may have the perverse effect of merely shifting societal stigma from one group—those with terminal medical conditions—to those whose suicidal behavior occurs in the context of psychiatric disorders. We do not need such a 2-tiered classification, in which there are good and bad methods of taking one’s own life.

Moreover, we believe that such a dichotomy would likely magnify disparities in end-of-life care in resource-poor areas, where MAID would be far less expensive than sustaining palliative care. The AAS position may also weaken the motivation and rationale for suicide prevention, during a period when suicide rates have been rising in the US.

 We believe that efforts to promote MAID would be better directed toward destigmatizing the mental illnesses that underlie the majority of suicides and toward bolstering the availability of state-of-the-art palliative care.

The American College of Physicians has said

Physician-assisted suicide is neither a therapy nor a solution to difficult questions raised at the end of life. On the basis of substantive ethics, clinical practice, policy, and other concerns, the ACP does not support legalization of physician-assisted suicide. … However, through high-quality care, effective communication, compassionate support, and the right resources, physicians can help patients control many aspects of how they live out life's last chapter.

Like the ACP, we reject the implication that merely legalizing MAID somehow means that it is consistent with ethical medical practice. Quite the contrary. As physician and ethicist 

, MD, has pointedly cautioned: “We must care for the dying, not make them dead.”

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of 

is a psychiatrist on the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana. 

is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is also a health care ethicist with the Ethics Consultation Service of the Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College, and serves as the Ethics Editor for 

is Director, Forensic Psychiatry Fellowship, University of Maryland, Baltimore, MD.

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. June 11, 2021. Accessed June 20, 2021. 

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3. Sulmasy DP. Physician-assisted suicide and the perils of empirical ethical research. 

6. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide. 

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9. Boer T. Does euthanasia have a dampening effect on suicide rates? Recent experiences from The Netherlands. 

10. Dworkin G. Suicide, strictly speaking. 3 Quarks Daily. July 22, 2019. Accessed June 23, 2021. 

11. Koch T. The ethicist as language czar, or cop: "end of life" v. "ending life". 

12. Pies RW. How does assisting with suicide affect physicians? 

. January 7, 2018. Accessed June 20, 2021. 

13. To live each day with dignity: a statement on physician-assisted suicide. United States Conference of Catholic Bishops. June 16, 2011. Accessed June 23, 2021. 

14. Levin TT, Applebaum AJ. Acute cancer cognitive therapy. 

15. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2019 Data Summary. February 25, 2020. Accessed June 23, 2021. 

16. Loggers ET, Starks H, Shannon-Dudley M, et al. Implementing a death with dignity program at a comprehensive cancer center. 

17. Cerel J, Battin MP. Statement of the American Association of Suicidology: “Suicide” is not the same as “physician aid in dying.” American Association of Suicidology. October 30, 2017.

18. Martuzzi M, Bertollini R. The precautionary principle, science and human health protection. 

19. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2020 Data Summary. February 26, 2021. Accessed June 23, 2021.

20. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. 

21. Macomb County Suicide Prevention Coalition. Holding onto life toolkit. Accessed June 23, 2021. 

22. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999-2018. 

23. Snyder Sulmasy L, Mueller PS, Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians Position Paper. 

A comparison of physician-assisted/Death-with-Dignity death and suicide patterns in older adult women and men

Are physicians who assist in suicide betraying their professional values?

. June 15, 2021. Accessed June 23, 2021. 

Pies RW, Hanson A. Twelve myths about physician assisted suicide and medical aid in dying. 

https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide

Should psychiatrists help patients end their own lives, even if it is technically legal? 

Against Assisted Suicide 

The fairest rules are those to which everyone would agree if they did not know how much power they would have. – John Rawls

When the welcome news of effective vaccines for COVID-19 arrived in December 2020, the country shared a collective sigh of relief. Yet, the hard work was still in front of us. One fact always remains true in medicine: We have limited resources (ie, manpower, medications, hospital beds, organs, etc) with which to treat the population. In this instance, the overriding question was how would we, as a society, determine who gets the first shots?

Three primary ethical frameworks have guided COVID-19 

 and prioritization in the United States: those formulated by the Centers for Disease Control and Prevention (CDC),

 and Johns Hopkins University’s Center for Health Security.

Unfortunately, a review of the frameworks reveals a relative 

 with serious mental illness (SMI) and the practitioners who treat them.

 This raises many important questions: How is it that, yet again, patients with SMI and substance use disorders (SUD) have been marginalized, in this instance from vaccine allocation protocols? What are the clinical and ethical imperatives to ensure there is equity in access? And how can mental health professionals promote a true community of immunity?

The 3 frameworks’ prioritization schemes are summarized in 

, and a quick study of the interrelated epidemiological and ethical grounds upon which they are based makes it even more surprising that there is no explicit inclusion of patients with SMI and SUD. Phase 1b of the National Academy of Sciences framework prioritizes adults with comorbid conditions that place them at significantly higher risk of illness and death from COVID-19, as does phase 1c of the CDC guidance. Johns Hopkins also places in tier 1 those at greatest risk of severe illness and death, and their caregivers. Results of high-quality research conducted before the pandemic have repeatedly identified that patients with SMI have life expectancies 25 years lower than those of the general population, mostly due to rates of medical comorbidities that are 2 to 3 times higher than average.

Table 1. Empirical Facts and Ethical Reasoning Supporting Prioritization of SMI for COVID-19 Vaccination

A study of more than 25,000 patients showed that even in the integrated Kaiser health care system, patients with SMI were 1.5 times more likely to have a number of serious and chronic health conditions, including obesity, diabetes, and cardiovascular disease.

 Many of these same conditions are associated with a higher risk of 

 Indeed, data from China indicate that the SMI cohort is at higher risk of contracting the virus, developing severe cases of COVID-19, being hospitalized, and dying.

 Individuals with SUD, especially opioids, are also at elevated risk of serious illness and death both from COVID-19 and overdoses related to pandemic-induced isolation and stress. Yet so far, in terms of SUD, states have prioritized only those with tobacco use disorder.

Phase 2 of the National Academy of Sciences prioritization scheme does specifically list and include individuals in homeless shelters and group homes; those with disability and mental illness; and those in prisons and jails. These populations are often overlapping: The percentage of 

patients with serious mental illness who are homeless

 and the prevalence of mental illness among those incarcerated in jails and prisons is between 15% and 20%.

 When the first wave of the virus hit New York, the strongest factor associated with case fatality rates, after age, was schizophrenia spectrum disorders.

These figures alone would support giving individuals with mental illness prioritization for vaccination. Vaccination of the significant population of individuals with SMI who live in various congregate settings is often the most feasible, and hence ethically compelling, means of protecting residents and caregivers from the virus. Many patients with SMI may find it extremely difficult to adhere to strict infection control protocols, and limited access to mental health care may lead to worsening of symptoms that then magnify risk of infection.

The intrinsic symptomology of SMI and substance use—such as paranoia, apathy, depression, and disorganization, as well as the psychosocial context that existed even before the pandemic, such as isolation, poor self-care, unemployment, and fear of the medical establishment—makes this population meet almost every definition of vulnerability.

 opined that the adverse social determinants of health for the SMI population are so entrenched and significant that, ethically, they should constitute a distinct category of health care disparity. If such a designation were formally recognized, it would obviously require vaccine and other potential therapeutic allocation frameworks to rethink the prioritization of SMI.

In the past, thought leaders as diverse as Pope John Paul II and President Harry Truman stated, in essence, that “a society will be judged on how it treats its weakest members.” Prioritizing 

 for individuals with SMI and SUDs, people who have long borne a stigma in American health care, promotes the “equal concern” principle of the National Academies. This principle encompasses the idea that every individual has intrinsic worth, dignity, and value, and such prioritization would answer the CDC’s call to remove unfair and avoidable barriers to vaccination as a matter of justice. Even when the scenario is viewed from a classic public health ethics perspective—as De Hert has persuasively argued—protecting the health of the public requires reducing exposure among those cohorts with high probability of exposing others, and among those least likely to take steps to prevent transmission of the virus.

Given these formidable scientific and ethical arguments for the vaccination of those with SMI and SUD, their comparative neglect in major allocation frameworks likely reflects long-standing systemic social determinants of mental health treatment. These determinants have resulted from lack of economic parity, intrinsic social stigmatization, cultural bias, absence of legal representation, and political disenfranchisement, among many other complex and unjust causes.

The ethical impetus to ensure COVID-19 vaccinations for individuals with SMI and SUD becomes even more urgent when the external and internal obstacles to vaccination among this population are considered. These obstacles are far more formidable than those facing other cohorts who are ranked higher in the allocation protocols. There is a disturbing dearth of research on routine preventive vaccination in the SMI and SUD population, although it is known that the cohort has very low rates of routine vaccination relative to the general population. More encouragingly, results of a recent pilot quality improvement project, involving a collaboration with the local public health department, increased preventive vaccination rates in a community outpatient mental health clinic.

 Recent articles offer recommendations for overcoming systems- and individual-level barriers to COVID-19 vaccination for individuals with SMI and SUD, respectively (

Table 2. Obstacles to Vaccination (and how to overcome them)

Individuals with SMI and SUD lacked parity in health care before the pandemic, and COVID-19 has massively exacerbated existing inequalities. These individuals often do not have access to the primary means of health care delivery and of arranging vaccine appointments in the pandemic: electronic communication technology. Patients with SMI often lack the knowledge, skill, and infrastructure to utilize it even when it is available. Internal obstacles only compound these external barriers. These include mistrust of the health care system (due to past histories of abuses), low health literacy about COVID-19, and lack of information about the vaccine. A recent set of interviews with individuals with SUDs assessed vaccine readiness and identified significant mistrust among respondents.

 In 2020, the Addiction Policy Forum interviewed 87 individuals about their readiness to receive the COVID-19 vaccine; all were either using substances, in treatment for substance use, or recovering from substance use disorders. Just 45% said they were ready immediately; of the rest, 8% said they would be ready after a delay, 23% were uncertain, and 25% were unwilling to take the vaccine. The reasons participants offered to explain their 

 included concerns about the rapid development of the vaccine, potential adverse effects, potential interactions with current medical problems, doubt that they were at serious risk for developing COVID-19, and mistrust of the government.

Not only patients with psychiatric disorders but also the practitioners who treat them have reason to fear being in the back of the vaccination queue. Health care workers are in phase 1a of the CDC guidance, high-risk health workers are in phase 1a of the National Academies of Science allocation protocol, and Johns Hopkins includes in tier 1 those most essential to sustaining the ongoing COVID-19 response. While most readers of 

 would likely assume that psychiatrists and other mental health practitioners would be included in all of these phases/tiers, this assumption was not widely shared outside of circles of mental health professionals.

How can mental health professionals promote a true community of immunity?

Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS

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