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

It’s complicated.” When we say this in everyday conversation, we usually mean we don’t want to talk about the subject because we either don’t have the time or we don’t have the inclination to explain to the person asking about it. Not so with our intrepid authors of this Special Report. They were willing and-as you will see-able to respond to our invitation to deploy their unique expertise to write about several different types of complicated patients.

When, as the Chair of this Special Report, I virtually sat down with the editorial staff of 

 to brainstorm topics we took a phenomenological approach rather than an analytic one. We used our collective experience to intuit areas of psychiatric practice where complicated patients would likely be encountered without restricting our imaginations or those of our authors with a definition. Let me work backwards here and circumambulate a definition not discursively but descriptively using synonyms.

 Dictionary gives us is “complex” as in “compound” and the opposite of simple. My favorite thesaurus, Roget’s 

, lays out a verbal feast for the close cousin, “complex”: anfractuous. Full of windings and intricacies. Convoluted. Complicated; intricate; twisted and coiled. Daedal. Extremely intricate and complex; skillfully made. Inextricable. Incapable of being disentangled or united: hopelessly complex. Involute. Intricate; involved. Tortuous. Winding; full of twists and turns.

It is certainly true that none of our articles in this Special Report deal with simple kinds of patients; and all of our authors had to assemble many moving parts for their coherent, comprehensible pieces.

We often make the mental health treatment world convoluted for those patients who are deaf or hard of hearing in ways those without hearing loss often do not appreciate. Fortunately, the article by Kimberly Mathos, DO, MPH, raises our cultural competence in being able to communicate professionally with persons who are deaf or have hearing loss so that we can make a better diagnosis and treatment plan.

Diabetes is a systemic chronic disease, and though as physicians we are well aware of the detrimental effect of diabetes on the heart, kidney, nerves, and eyes, we often forget that it is inextricably bound up with psychiatric symptoms. Awais Aftab, MD, Sidra Qadir, MD, and Muhammad Hasnain Abbas, MD, provide a primer on the management of anxiety disorders in individuals with diabetes.

Finally, these days many of the most exciting new research articles are on pharmacogenetic studies. It may be that my brain is just getting old, but I find these to be very torturous articles. Alessandro Serretti, MD, PhD, and Chiara Fabbri, MD, PhD, untangle two of the most cutting-edge areas in psychiatry: treatment resistance and pharmacogenetics. Their overview of how pharmacogenetics can be a powerful tool to overcome the obstacles of treatment resistance is user-friendly for old and young psychiatrists alike.

These thumbnail sketches of the articles in this Special Report produce an impressionistic sketch of the meaning of the word complicated in psychiatric practice.

A patient can be complicated because of an unusual presentation we were not trained to assess, such as a deaf person. A patient can be complicated for one practitioner and yet not for another: a psychiatrist who has a strong basic science background such as our new Editor-in-Chief probably finds subjects like pharmacogenetics to be easy reads whereas a medical psychiatrist like myself would feel far more able to understand an article about diabetes patients who have anxiety.

Treating a patient may be complicated because of a lack of resources in the community or knowledge of how to access those resources. And last but not least, a patient may be complicated as a result of having too many cooks in the prescribing kitchen who are faced with a multi-symptom patient in an era in which medication management is both our blessing and our curse as clinicians.

We hope these perspectives on different types of complicated patients will improve your ability as practitioners to understand and treat these complex patients in your own practice.

Dr Geppert is Professor, Department of Psychiatry and Internal Medicine, and Director of Ethics Education, University of New Mexico School of Medicine in Albuquerque, NM; she is also Health Care Ethicist, Ethics Consultation Service, VA National Center for Ethics in Health Care. She is also an Editorial Board Member of 

Roget’s Thesaurus of Words for Intellectuals: Synonyms, Antonyms, and Related Terms Every Smart Person Should Know How to Use.

Articles

Introduction: A Lexicon of Complex Patients in Psychiatric Practice

“Assisted Dying,” “Medical Aid in Dying” (MAID), “Physician Assisted Suicide”(PAS)-by whatever label we attach to it controversy continues to swirl around the practice of prescribing a lethal drug for a patient with a putatively 

 (For now, let’s leave aside the point that physicians are notoriously bad in predicting when a patient will die, getting it wrong about 80% of the time and underestimating life expectancy in about 17% of cases.

To be clear: people of conscience, including many physicians, are 

 regarding whether, and under what conditions, MAID/PAS may be ethically justified-even when it is legal.

 The challenges of providing end-of-life care that preserves the patient’s humanity and minimizes pain and suffering are complex and daunting. We do not believe there are simple, universally applicable clinical or ethical options for addressing these challenges. However, in this essay, we argue that support for “assisted dying” as the preferred option is founded on numerous misconceptions regarding existing MAID/PAS statutes, among both the general public and many physicians. Here, we discuss two fundamental misconceptions: the myth of the patient’s autonomy, and the myth of the incurability of the patient’s illness.

The term “autonomy” literally means, “living by one’s own laws” (

 “law:). In medical ethics, as Beauchamp and Childress explain,

Personal autonomy is, at minimum, self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice. The autonomous individual acts freely in accordance with a self-chosen plan. . . . A person of diminished autonomy, by contrast, is in some respect controlled by others or incapable of deliberating or acting on the basis of his or her desires and plans.”

 pertains as much to norms of moral conduct derived from reason as it does to external political rules.

 The two myths we discuss-though enshrined in the laws of PAS-permissive states-lack any foundation in well-reasoned ethical principles. Thus, proponents of MAID/PAS statutes typically argue that these laws are grounded in the patient’s “autonomy,” and establish “the patient’s right to die” or “the right to death with dignity.” Yet the US Supreme Court has never recognized a constitutionally based “right to die;” a “right to commit suicide;” or a “right to assisted suicide,” although it has 

 a competent patient’s right to refuse life-saving treatment.

 The Supreme Court’s rulings (eg, Washington v Glucksberg and Vacco v Quill) stand in a long line of legal precedent and common law tradition, reflecting foundational Anglo-American philosophical and religious values. These include the state’s legitimate interest in safeguarding human life and preserving the integrity of the medical profession.

-modeled closely on the 1997 Oregon “Death with Dignity” statute-reveals that these 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.

In contrast, when competent patients refuse life-sustaining care or choose “voluntarily stopping eating and drinking” (VSED), they are making genuinely autonomous choices.

 These options may allow patients to regain a sense of control and self-direction. Palliative and hospice care, at their finest, are about empowering such patient-driven choices. Ironically, as Varelius observes, “. . . in voluntary euthanasia and physician-assisted suicide . . . one ceases to be an agent and loses control over one’s life.”

The famous libertarian and critic of psychiatry, Thomas Szasz, was one of the first to “call foul” on the notion of patient autonomy in MAID/PAS. As Szasz succinctly puts it in his book, 

. . . the legal definition of PAS as a procedure that only a physician can perform expands the medicalization of everyday life; extends medical control over personal conduct, especially at the end of life; and diminishes patient autonomy.

Indeed, Szasz’s analysis makes clear that the patient who elects PAS is not making a procedurally autonomous decision, but a heteronomous one (ie, subject to a law or standard external to oneself). Ironically, this heteronomy is a form of paternalism that actually undermines the patient’s autonomy by surrendering control to “the other,” be it physician or government. Not coincidentally, Szasz regarded physician-assisted suicide as little more than “bureaucratized medical killing.”

Of course, there is much more at stake in this debate than mere procedural autonomy (ie, the ability to “command and control” a particular sequence of events or procedures). At issue is what we would call authentic autonomy, which reflects both the psychology and the core internal values of the person. How, then, is the patient’s authentic autonomy assessed under current PAS statutes? To what degree is the patient’s genuine informed consent ensured? And are there sufficient safeguards under current PAS statutes to ensure that the patient does not have a psychiatric disorder that would impair understanding and undermine informed consent? Can a person in such existential distress truly exercise the voluntarism that is integral to authentic autonomy? We believe that, under current MAID/PAS regulations, these critical issues have not been given serious moral consideration.

Indeed, as our colleague, Dr. James L. Knoll IV, has written,

. . . problems not likely to be resolved anytime soon include: the lack of a widely accepted capacity assessment for PAD [physician-assisted dying]; the absence of any legally defined test for capacity to consent to PAD; clearly distinguishing depressive symptoms from a “rational” wish to die; and the fallibility of evaluators…This would seem to lead into a morass of fundamentally subjective determinations.

Furthermore, it is not true that under current PAD statutes “. . . mental illness that would affect the rationality of decision-making is screened out,” as erroneously claimed in a position paper from the American Association of Suicidology.

 One of the most profound and misunderstood limitations of statutes modeled after the Oregon Death with Dignity Act is that they do not require examination by a mental health professional, except when the participating physician is “concerned” and decides to do so. In fact, in Oregon, 204 patients were prescribed lethal drugs in 2016 under the “Death with Dignity” statute, yet only 5 patients were referred for psychiatric or psychological evaluation.

But let’s assume that an ideal assessment process is available; that the physician utilizes it when the request for “aid in dying” is made; and that the physician finds the patient to have the requisite decision-making capacity under the law to receive the lethal prescription. This says little about the patient’s state of mind once he or she leaves the office with the prescription. There remains a huge informational gap, since the physician can in no way guarantee that, once in the home setting, the patient’s decision is free from familial pressure, economic coercion, or “conflicts of interest.”

Under current “Oregon type” statutes, there are no mandatory procedures in place that comprehensively evaluate the dynamics of the patient’s severely stressed family system. For example, does the patient have a family member who stands to gain from the patient’s suicide-by, say, inheriting a large sum of money, or being freed from the burden of caring for the patient? Oregon-type PAS statutes do not even require that a health care professional be present at the time of the lethal ingestion-and in most cases, no such professional is present. All these factors tend to undermine authentic autonomy, as Varelius notes: “If a person’s choices, decisions, beliefs, desires, etc are due to such external influences as . . . socialization, manipulation, coercion, etc, they are not autonomous.”

Rather, current PAS statues create a superficial “pseudo-autonomy” that is, at best, cosmetic in nature. Procedural boxes may be checked, but the underlying conscious and unconscious motives of those involved are virtually ignored. In particular, the role of transference, countertransference, and coercion in PAS decisions has been sorely neglected, as have the unconscious fears and fantasies of the patient requesting PAS. Indeed, “. . . coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide.”

Authentic autonomy cannot be assessed without an understanding of these psychodynamic issues. Specifically, as Hicks notes,

In any suicidal patient, including the terminally ill, the request to die can be a plea for help or an attempt to be given a reason to live. A request for PAS can be an entreaty for the doctor to take the terminally ill patient's situation or despair more seriously, or a test of the doctor's true feelings about the patient's value now that he is nearing death.

Finally, it is important to recall that autonomy is only one of the four “cornerstones” of medical ethics; the others are beneficence, non-malfeasance, and justice.

 Many would argue that helping one’s patient kill herself is hardly beneficent-and, indeed, constitutes 

 Furthermore, we must remember that the supremacy of autonomy is a relatively recent development in the history of ethical thought-one that many ethicists believe has become unduly preeminent.

 As Tauber has argued, “Complex social and economic forces have placed patient autonomy at the center of medical ethics, and thereby displaced an older ethic of physician beneficence.”

 Indeed, as Desai and Grossberg observe in their textbook on long-term care,

The preeminence of autonomy as an ethical principle in the United States can sometimes lead health care providers to disregard other moral considerations and common sense when making clinical decisions . . . we strongly feel that the role of the medical profession is to understand but not to support such wishes [for physician-assisted death]. Every person’s life is valuable, irrespective of one’s physical and mental state, even when that person has ceased to deem life valuable.

Re-defining incurability and terminal illness

Most PAS legislation applies to an adult with a terminal illness or condition predicted to have fewer than six months to live. The common interpretation of this phrase would be, “six months to live even with treatment,” often with the assumption that there is no further or additional therapy capable of halting or reversing the disease process. Good law and sound public policy both depend upon clear and cogent definitions. Yet, incredibly, “terminal illness” is never defined at this level of detail in existing PAS statutes (ie, with respect to treatment vs no treatment). Nevertheless, in Oregon and Washington State, nearly identical criteria are interpreted to mean fewer than six months to live without treatment. Thus, an otherwise healthy 20-year-old with insulin-dependent diabetes could be deemed “terminal” for the purpose of Oregon’s “Death with Dignity Act,” since, without insulin, the patient would probably die within six months.

So, too, patients refusing appropriate treatment may be deemed “incurable” or “terminal” under current 

 Thus, a patient with anorexia nervosa who refuses treatment could be eligible for PAS under Oregon law, even though she has never tried a course of intensive, evidence-based therapy. By this Orwellian logic, an individual with pneumonia who refuses to take antibiotics could be deemed “incurable” and qualify for physician-assisted suicide! As Swedish investigator Fabian Stahle dryly observes, “This is in fact an alteration of the traditional meaning of the concept of ‘incurable’ . . .”

In a remarkable, notarized exchange with the Oregon Health Authority, Mr. Stahle posed the following questions:

In the [Oregon] law, “terminal disease” is defined as an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment (in the opinion of the patient’s attending physician and consulting physician), produce death within six months. Is this rule interpreted as “without administration of life-sustaining treatment”?

Craig New, Research Analyst, Oregon Health Authority, Center for Public Health Practice, Public Health Division, replied as “ . . . your interpretation is correct. The question is: should the disease be allowed to take its course, 

, is the patient likely to die within six months?” [emphasis added]

As Mr. Stahle rightly concluded, “So under Oregon’s assisted death law, one can achieve the status of being “incurably” sick even if the disease can be treated! Thus, all diseases which, without treatment, are expected to lead to death within six months are considered to be incurable and therefore qualify for assisted death.”1

Stahle then posed a follow-up question to Mr. New:

If a patient with a chronic disease (for instance, diabetes) by some reason decides to opt out from the life-sustaining medication/treatment and by doing so is likely to die within 6 months, thereby transforming the chronic disease to a terminal disease-does he/she then become eligible to take use of the act?

New replied that, yes, indeed-the patient would qualify for assisted suicide. In New’s words, the Death With Dignity Act “. . . does not compel patients to have exhausted all treatment options first, or to continue current treatment . . . [and] if patientS decide they don’t want treatment, that is their choice.”

There is certainly room for debate regarding the role of the physician in “end-of-life” care. Nonetheless, as psychiatrists and medical ethicists, we believe that so-called “medical aid in dying” (physician-assisted suicide) is a serious boundary violation and an unethical act. This is consistent with the historical positions of the American Medical Association, the American Psychiatric Association (based on the AMA Code of Ethics), the American College of Physicians, the World Medical Association, and the American Nurses Association.

Whatever individual physicians decide with respect to MAID/PAS, it must be based on a clear-eyed understanding of current statutes and legislation. This means exposing the 

 Among these are the commonly-received notions that patients choosing PAS act “autonomously” and have a demonstrably incurable condition. In truth, current PAS statutes produce a form of pseudo-autonomy that enshrines the supreme authority of the physician, and re-defines “incurable” to mean almost anyone who is seriously ill.

This article was originally published on 7/18/18 and has since been updated.

Letter to the Editor by Susan Stefan, Esq.

As the author of a recent comprehensive survey of suicide and the law in the United States and around the world [

Rational Suicide, Irrational Law:Examining Current Approaches to Suicide in Policy and Law

 (Oxford University Press 2016)], I was very interested in this thought-provoking article.

Like the authors and Thomas Szasz, I oppose medicalizing what is essentially a very personal and philosophical decision, for a variety of reasons. Most importantly, I am skeptical about third-party involvement in suicide. Under current law in states that approve physician-assisted suicide, any physician can theoretically examine a patient who is a perfect stranger to him or her and then write a prescription two weeks later. I am uneasy about giving this kind of power to a stranger just because he or she went to medical school; even doctors have political agendas. I am most uneasy about the fact that suicide is self-limiting, but a doctor can assist an unlimited number of suicides. When the New England Journal of Medicine conducted an anonymous survey of doctors prior to the adoption of the Oregon ballot measure, doctors were asked if they had facilitated one or more deaths, and, for those who answered affirmatively, the range was one to one hundred and fifty. This was before any legalization of physician-assisted suicide.

As to the second "myth," the United States and the state of Victoria in Australia are the only places in the world where legal assisted suicide is limited to a terminal illness with a six month window, for the very reason that Drs. Geppert and Pies underscore: if the underlying rationale purports to be patient autonomy, there is no logical reason to limit the practice in a way that is so open to the physician's subjective and fallible judgment.

However, if Drs. Geppert and Pies truly embraced these arguments about autonomy,  they would support (as I do) the right of competent, non-intoxicated adults to make a rational decision to end their lives, without regard to further "qualifying" conditions such as illness or unbearable pain, and therefore support the abolition of long-term civil commitment for suicidality (short holds to ascertain competence and sobriety may be necessary to ensure that a person is acting as an autonomous agent.) I suspect they do not do this.

Ultimately, Drs. Geppert and Pies and I share common ground in our profound feelings that whatever the outcome of the policy debate, a movement where a doctor's providing a patient with the means of ending his or her life is increasingly being denominated as "treatment" is one bearing close scrutiny about the role of physicians in our society.

Susan Stefan, Esq.


Susan Stefan is a practicing attorney and scholar who will be a visiting Professor of Law at the University of Miami School of Law in the spring semester of the 2018-19 academic year.

Dear Attorney Stefan,

Thank you very much for your thoughtful letter in response to our article on physician-assisted suicide. It appears the three of us share a number concerns re: the pitfalls of this practice, which, presumably, we would all agree is not a medical "treatment."

That said, as psychiatrists and medical ethicists, we may have a somewhat different perspective than you, as regards the notion of "rational suicide" and the patient's autonomy. Specifically, with respect to your statement:

"However, if Drs. Geppert and Pies truly embraced these arguments about autonomy,  they would support (as I do) the right of competent, non-intoxicated adults to make a rational decision to end their lives, without regard to further "qualifying" conditions such as illness or unbearable pain, and therefore support the abolition of long-term civil commitment for suicidality (short holds to ascertain competence and sobriety may be necessary to ensure that a person is acting as an autonomous agent.) I suspect they do not do this.

We would make the following points:

1. We would distinguish between "rights" and "liberties", as Szasz does in his book, Fatal Freedom; i.e., a "right" entails the cooperation or acquiescence of some specified "other"; a liberty does not. Thus, people are at liberty to smoke, with no "right" to have others "assist" them. There may be a carefully qualified case [see below, #3] for asserting that mentally competent persons ought to be "at liberty" to end their own lives; but we would not recognize any "right" to do so--and certainly, we recognize no right to obtain the cooperation of others, especially physicians. (Moreover, as you know, the U.S. Supreme Court, in the two landmark 1997 decisions of Vacco v. Quill and Washington v. Glucksberg, did not recognize any constitutionally-based "right to commit suicide" or to receive assistance in suicide) [1].

The distinction between liberties and rights is roughly analogous to the distinction, in medical ethics, between “negative rights” (e.g., the right to refuse treatment) and “positive rights” (the right to demand that something be done, such as an operation). Positive rights are more circumscribed in medicine, since they normally entail cooperation or intervention by someone other than the patient.

2. We recognize the long-standing claim that suicide can be "rational", and that there are philosophical roots to this claim (e.g., as you may know, the Stoics believed that, under certain carefully considered circumstances, suicide could be justified). However, as psychiatrists, we are deeply skeptical that suicide can truly be a "rational" act, except possibly in a minuscule number of cases. To be sure, this may reflect the population of persons we see and treat. However, as you know, there is an abundant literature showing that, in the vast majority of cases, suicide occurs in the context of serious psychiatric illness, such as major depressive disorder, bipolar disorder, and schizophrenia [2].

That said, we acknowledge that suicide can sometimes occur in the absence of a formal psychiatric disorder or diagnosis; e.g., Pridmore's concept of "predicament suicide" in response to an overwhelming stressor. [3] But even in such putative "non-psychiatric" cases, we would still question the "rationality" of such a decision. In our clinical experience, stress-driven, impulsive suicides (which were not what the Stoics defended) are typically grounded in cognitive distortions or irrational ideas; e.g., "My family would be better off without me," or "I'll never find anyone to love me again!" etc. --even when the suicidal person is convinced he or she has arrived at a perfectly "rational" decision.

For these reasons, we believe that all suicidal persons merit careful psychiatric evaluation. This may sometimes be accomplished within the framework of what you reference as "short holds to ascertain competence and sobriety"--but not always. Sometimes a longer stay (e.g., greater than the usual 72-hour emergency "hold") is needed to clarify the person's competency and autonomy.

3. Nevertheless, we would agree that, in the rare instance in which a suicidal person is completely without signs of psychiatric illness; in full command of his/her mental faculties; and free of undue external pressures, long-term institutionalization ("civil commitment for suicidality") is unlikely to be helpful, from the clinical standpoint.

To be clear: in saying that a “rational” suicidal individual should not be involuntarily committed, we are not perforce endorsing the act or its motive. Rather, we are saying that our current mental health policies and laws provide no ethical justification for depriving a person of liberty when there is no likelihood of clinical benefit sufficient to warrant that deprivation. Of course, as you know, long-term civil commitment is not a psychiatric/medical decision, but one reserved for the courts, magistrates, and (one hopes) due process of law.

All that said, we can understand why you, as an attorney, would advocate for "the abolition of long-term civil commitment for suicidality." And perhaps there is merit in this position. However, we view this as a moral decision that our society as a whole must make--and not simply on the basis of "autonomy." As the U.S. Supreme Court held in the Glucksberg case, other values may also come into play--particularly the state's interest in the preservation of human life [4]. As ethicists, we also believe that certain "communal values" ought to be part of the discussion.[5] After all, a society that condones suicide--even in the case of competent, autonomous persons--runs the risk of devaluing human life and encouraging "copy cat" suicides, which appears to be the case in Oregon. [6]. As John Donne famously put it, “No man is an island…”

Perhaps, then, we can all agree that "physician assisted suicide" has no foundation in medical ethics, and that current PAS laws are untenable and severely flawed. Again, we thank you for your stimulating comments on our article.

Sincerely,
Ronald W. Pies, MD
Cynthia M.A. Geppert, MD, DPS, MPH

References
1. 

https://biotech.law.lsu.edu/cases/pro_lic/vacco_glucks_brief.htm

https://www.ncbi.nlm.nih.gov/pubmed/12701661

http://journals.sagepub.com/doi/abs/10.1080/10398560802614158

http://www.upstate.edu/psych/pdf/szasz/pies-suicide-communal-values.pdf

http://alexschadenberg.blogspot.com/2018/08/in-oregon-other-suicides-have-increased.html

I am bewildered as to why Ms. Stefan would choose specifically “intoxication“ as an eligible disqualifying state of mind for rational suicide, rather than many other similar disturbed, distorted, and distressed states of mind that we encounter as psychiatrists- as Drs. Pies and Geppert referred to in their response. In fact, we psychiatrists have a skill set to help people pass through these states, independent of any particular “diagnosis.“  Our skill set and our ethical duty is to minister to distress in the domain of mental life, whether there is a “diagnosable” mental condition or not. If people come knocking on our door, or are brought to us by concerned family or authorities, I  believe that it is unethical for society to expect us to do anything other than “our thing“ -which is to accompany people in those states of mind and attempt to support and ameliorate their suffering. That’s what it means to be a physician psychiatrist.  Psychiatrists in particular do not provide suicide; we prevent suicide. 

The problem is that authors like Ms. Stefan (and most who write about “rational suicide“ as well as support PAS) are not physicians and are not acculturated, educated, and steeped in the ethos of the medical profession in general, and psychiatry in particular.  We, of course, have our own ethics, mission, limitations on our choices, and values that we “profess.” To non-physicians who write about this, these notions seem irrelevant, or secondary at best. Yet it is vital that society preserve and protect physicians’ capacity to evince and hew to their own ethical codes and values. The famed anthropologist Margaret Mead, wrote to a psychiatrist friend:

“The followers of Hippocrates were dedicated completely to life under all circumstances. . . This is a priceless legacy which we cannot afford to tarnish. But society has repeatedly attempted to make the physician into the killer… It is the duty of society to protect the physician from such requests.”

Embracing its own code of ethics and that of the AMA, the APA deployed its right, even duty, to assert professional values and ethical principles for Psychiatry in its recent Position Statement: “a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”

Entering into the House of Medicine is different from entering into one’s own house, or entering into the houses of parliaments and legislatures.  These are not identical ethical spaces. Indeed, effacing those differences is exactly what happened when physicians, especially psychiatrists, participated in the forced sterilization movement in the US and the Nazi T4 program to exterminate the mentally ill in Germany.

I’m also gratified that Drs. Pies and Geppert brought out the idea that there are other considerations besides individuals’ autonomy, and that society and policymakers need to be mindful of such other considerations involving the “common good.“ Their references include important work demonstrating that there may in fact be a suicide “contagion” effect of PAS and euthanasia. 

https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2016-Medical-Euthanasia.pdf

http://www.hippocraticregistry.com/?page_id=1934

Mark S. Komrad MD, DFAPA
Faculty of Psychiatry, Johns Hopkins
University of Maryland, Sheppard Pratt

Letter to the Editor by Johan Verhulst, MD, FACP

I agree with Dr Pies that most patients, who make a request for physician-assisted suicide (PAS) do so because they fear loss of dignity and control over their own lives. However, if a well-meaning physician were to respond to my request for PAS by instead offering psychiatric counseling as Dr Pies suggests, I would likely perceive this as an implicit pathologizing of both my realistic fear and my healthy desire for autonomy and control at the end of my life.

On the other hand, the thorny issue of PAS could very well be resolved if the medical profession were to relinquish some of its control over people’s access to barbiturates in the specific circumstance of end of life care. Imagine for instance that physicians were to propose, or at least support, new legislation in Oregon and Washington, legislation that would abolish PAS (!) and replace it with the following: Physicians would notify the patient when they believe that the latter has less than 6 months to live. This probable prognosis would be entered on an official form. The patient can request a second opinion and that physician can complete the form by entering a concurring opinion. The prognostic information may only inspire the making of final arrangements, but the patient could also hand the form over to a pharmacist in return for a lethal dose of barbiturates. Note that, both in Oregon and Washington, trained and experienced volunteers are available to help the patient with the practical challenges of freely chosen “Death with Dignity”.

A more shameful control over people’s access to barbiturates is exerted by the pharmaceutical industry. Indeed, patients are currently charged from one to more than three thousand dollars for a lethal amount of barbiturates, a class of medications that was developed more than one hundred years ago!

In conclusion, patients only desire to control their own life while the control, exerted by physicians, limits the autonomy and self-determination of another person, i.e. the patient. The autonomy-limiting effect of the medical control is a reality, which cannot be negated by ethical intentions or by the unshakable, yet totally unsubstantiated belief that --in the absence of manifest pathology-- physicians are capable of distinguishing between a healthy and an unhealthy desire to control the end of one’s life.

Respectfully submitted,
Johan Verhulst, MD, FACP
Seattle, Washington

In principle, I find much to like in your proposal to abolish PAS as it now exists (e.g., in Oregon) and to replace it with some type of system that does not involve physicians in writing out a prescription for a lethal dose of barbiturates. As you know, I find that practice inconsistent with the Hippocratic role of physician as healer. Proposals along the lines you suggest have been put forward by others in the medical or legal community; e.g., human rights lawyer Joel Joffe proposed a system whereby

“…The courts or another legal body would have the responsibility for investigating and determining whether a terminally ill patient suffering unbearably should be entitled to ask for assistance to die….”
See: 

https://www.theguardian.com/commentisfree/belief/2010/jul/28/assisted-suicide-dying

In principle, I am not opposed to legislative moves in this direction, since presumably the courts would have access to expert medical opinion; e.g., in assessing if the patient competent to make this request, whether the decision is being made under duress, etc.  Of course, I would need to see the details of any such hypothetical legislation, and I remain generally opposed to the concept of “assisted dying” on both ethical and practical grounds; e.g., I fear that the potential for abuse outweighs the supposed “benefits.”  We would be much better off as a society if we focused on providing comprehensive, “state of the art” palliative care to all terminally ill patients who would benefit from it.

As to your proposal: the problems I see with simply having patients declared “terminally ill” and then allowing them, in effect, to stop off at the pharmacy to pick up lethal medication is that there are no built-in safeguards. A system of that sort would not prevent, for example, a terminally ill person who was also severely depressed from obtaining lethal medication. Indeed, that system would seem to cut out the physician (including psychiatrists) from having any real input into assessing the patient’s state of mind; degree of genuine autonomy; coercive pressures from family members, etc. It could also be construed as a form of abandonment, in my view.

Sometimes, the “manifest pathology” you allude to is not so readily “manifest”, unless a careful evaluation is carried out; e.g, as you know, some patients may be “quietly psychotic” or proceeding on the basis of profound cognitive distortions. I do not have confidence that the average internist or oncologist is likely to pick up such problems.
As for protecting the patient’s “autonomy”, I think that is best protected by a careful assessment of all the factors that constitute authentic, rather than apparent, autonomy, as Dr. Geppert and I argue in our article.

On the other hand, let’s assume we want an alternative to PAS that doesn’t involve a physician’s judgment at all. (I am not including hospice care or palliative sedation here). There remains the option of voluntary stopping of eating and drinking (VSED). Even the famously libertarian critic of psychiatry, Thomas Szasz, saw this as a viable option for virtually all persons with terminal illnesses who wished to end their lives (see his book, Fatal Freedom).  And, contrary to much misinformation in the public forum, VSED does not entail a prolonged, painful period of “starvation”, and can be used at home concurrently with palliative sedation and family support. Indeed, one study by Ganzini et al (2003), based on hospice nursing assessments, found that “…As compared with patients who died by physician-assisted suicide, those who stopped eating and drinking were rated by nurses as suffering less and being more at peace in the last two weeks of life…” 

https://www.nejm.org/doi/10.1056/NEJMsa035086

Finally, regarding your concern that if a patient were offered psychiatric/psychological counseling as part of end of life care, he or she would likely perceive this as “pathologizing” realistic fears and a healthy wish for autonomy and control:  I can only say that while this reaction may be common, it does not justify our bowing out or withdrawing from our professional responsibilities as psychiatrists. A reaction of that sort is, alas, the result of the stigma attached to psychiatry and psychiatrists, and can be overcome only by teaching the general public that we can be helpful and-one hopes-wise counselors who do not prejudge or reflexively “pathologize” a patient’s motives. (Of course, a psychiatric social worker, clinical nurse specialist, or pastoral counselor could also provide helpful counseling in end-of-life settings).

Again, Dr. Verhulst, thank you very much for taking the time to write on this very complex issue.

1. Pies R. Brittany Maynard and the Loose Language of Suicide. 

https://www.medscape.com/viewarticle/835014

2. Pies R, Geppert CM. Not just a matter of semantics. 

http://www.psychiatrictimes.com/couch-crisis/not-just-matter-semantics

3. Christakis NA, Lamont EB. Extent and determinants of error in physicians' prognoses in terminally ill patients prospective cohort study. 

4. Starks H, Dudzinski D, White N, et al. Physician Aid-in-Dying. Ethics in Medicine. 

https://depts.washington.edu/bioethx/topics/pad.html

, 5th ed. New York: Oxford University Press; 2001: 58.

6. Lane M. Ancient political philosophy. Zalta EM, Ed. 

. Stanford University: Metaphysics Research Lab; 2017.

7. Waimberg J. Does the constitution protect a “right to die”? 

https://constitutioncenter.org/blog/does-the-constitution-protect-a-right-to-die

8. Oregon Health Authority. Death With Dignity Act: Revised Statute. 

https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx

9. Ganzini L, Goy ER, Miller LL, et al. Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. 

10. Varelius J. The value of autonomy in medical ethics. 

Fatal Freedom: The Ethics and Politics of Suicide

12. Knoll JL. Suicide prohibition: shame, blame, or social aim? Haldipur C, Knoll JL, Luft E, Eds. 

. NY: Oxford University Press (In press).

13. Statement of the American Association of Suicidology: Suicide Is Not the Same as Physician Aid in Dying. 

http://www.suicidology.org/Portals/14/docs/Press%20Release/AAS%20PAD%20Statement%20Approved%2010.30.17%20ed%2010-30-17.pdf

14. Oregon Death With Dignity Act: Data Summary 2016. 

https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf

15. Hicks M. Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors. 

16. Hallowell B. Why so many doctors oppose euthanasia and assisted suicide. 

https://www.deseretnews.com/article/865659304/Why-so-many-doctors-oppose-euthanasia-and-assisted-suicide.html

17. Pies R. Physician-Assisted Suicide and the Rise of the Consumer Movement. Psychiatric Times. August 2916. 

http://www.psychiatrictimes.com/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement

19. Wardrope A. Autonomy as ideology: towards an autonomy worthy of respect. 

Psychiatric Consultation in Long-Term Care

. Baltimore, MD: Johns Hopkins University Press; 2010: 262.

21 Stahle F. Oregon Health Authority Reveals Hidden Problems with the Oregon Assisted Suicide Model. January 2018. 

https://www.masscitizensforlife.org/oregon-health-authority-reveals-hidden-problems-with-the-oregon-assisted-suicide-model

The authors discuss two fundamental misconceptions: the myth of the patient’s autonomy, and the myth of the incurability of the patient’s illness.

Two Misleading Myths Regarding “Medical Aid in Dying”

For I do not seek to understand in order that I may believe, but I believe in order to understand. For this also I believe-that unless I believe I shall not understand.

Mrs. P is a 54-year-old woman admitted to the acute medical unit with uncontrolled hypertension secondary to non-adherence and a non-healing ulcer, the result of venous stasis related to high blood pressure. For the first few days of the hospitalization she is pleasant and cooperative with the medical team and nursing staff.

On a Saturday morning of her first week in the hospital, Mrs. P begins to say that she no longer needs treatment for her hypertension or wounds because “God has told her she is healed.” Despite this unusual claim, Mrs. P continues to participate in the treatment plan saying, “ I want to help the doctors and nurses, and so I will let them do what they need to do.

On Sunday Mrs. P begins to tell the team that she doesn’t need to be in the hospital because she is healed. The team is concerned that Mrs. P will try and leave against medical advice. They become seriously concerned about her decision-making capacity and advise Mrs. P that they feel she needs to stay in the hospital as her blood pressure is still not well-controlled and she needs wound care several times a day. Mrs. P says, “I cannot leave the hospital. I don’t need to be here for me as I am healed, but God wants me to remain until I have ministered to everyone in the hospital.” Mrs. P is still accepting treatment. The team is beginning to really question Mrs. P’s mental state.

The team decides to call psychiatry. Because Mrs. P believes she has been healed and has a mission, they are now sure that she suffers from a mental illness. In addition, Mrs. P increasingly says she does not need medication because she is miraculously healed. It takes considerable time and effort to persuade her to take the medication. The psychiatrist, Dr. H, sees Mrs. P on Monday morning and conducts an extensive interview as well as record review. Looking at Mrs. P’s records, Dr. H sees that Mrs. P had been seen several years earlier as an outpatient because of irritability and depressive symptoms for which antidepressants were prescribed. She stopped taking the medication and did not return for follow up. There is no history of psychiatric hospitalizations, suicide attempts, violence toward others, or psychotic symptoms. Psychosocially, Mrs. P has been married for 25-years, has no known substance use, and is working full-time as a salesperson at a department store.

Mrs. P talks freely and volubly to Dr. H about her religious beliefs. She describes herself as a lifelong Pentecostal Christian and quotes scriptures to support her faith. When contacted, her husband confirms that his wife has always been very religious and often preaches to others at church. Dr. H has had interactions with persons from similar faith traditions in her own upbringing and so does not find Mrs. P’s beliefs to be delusional but understands that they may seem so to the medical team. In Dr. H’s judgment, Mrs. P does not currently meet criteria for a serious mental illness, although she is somewhat labile, which Dr. H believes is likely due to the stress of hospitalization. Mrs. P assures Dr. H that she intends to stay in the hospital to receive needed treatment.

Two days later, Mrs. P begins wheeling herself into other patient’s rooms to save souls. She also removes the bandage from her wound. Dr. J and the medical team agree it is wise to ask the Protestant chaplain to see Mrs. P. When he comes, she politely declines to talk with him, saying she has her own pastor. Mrs. P tells the psychiatry resident the name of her church and pastor and that he can contact him. The pastor readily agrees to visit; he is a highly educated and psychologically astute minister. After more than an hour with Mrs. P he tells the psychiatry team that “our Church does believe in divine healing, but also that God heals through doctors. If you have a faith healing, there should be medical evidence. Mrs. P insists she is healed in spite of the evidence of her high blood pressure and infected leg, that is not rational. For now I have convinced her to work with the medical team.” Mrs. P’s response is that she respects her pastor but that he does not understand that God has performed a miracle.

 At this point in her care, is Mrs. P capable of informed consent for ongoing treatment?

 No, she is not capable of informed consent. Mrs. P is clearly suffering from religious delusions and cannot provide informed consent.

 Yes, she is capable of informed consent. As long as Mrs. P cooperates with care, there is no reason to question her capacity to provide consent. The reasons for which she is cooperating is irrelevant.

 Yes, she is capable of informed consent. Unless Mrs. P’s beliefs start to interfere with her treatment, they should be respected.

 No, she is not capable of informed consent. The belief in miraculous healing is incompatible with the ability to understand and reason regarding treatment.

 Does the health care team need to obtain further consultation? If so, from whom and why?

 The team should call for a consult from psychiatry because Mrs. P may be psychotic and she needs treatment.

 The health care team should call the hospital chaplain because they respect Mrs. P’s religious beliefs. This will provide the team with further guidance about how to best respond to her religious beliefs.

 The team should call Mrs. P’s husband because she has clearly lost capacity. As such, a surrogate decision-maker is needed immediately to prevent any harm to Mrs. P.

 The team should not call anyone. Mrs. P is still working and cooperating with the health care team, and e is not displaying any disruptive behavior. The team is just uncomfortable with her religiosity and should not overreact.

 If you were the ethics consultant, what issue you might you raise at this juncture?

 A chaplain or other religious professional should be the one to determine if Mrs. P’s beliefs are congruent with a recognized faith tradition and if this is outside the psychiatrist’s scope.

 It does not matter if Mrs. P’s religious expression coheres with any organized religious group; her own personal spirituality should be respected as in accordance with a commitment to cross-cultural sensitivity.

 Mrs. P’s religion and spiritualty are not the central concern, and she does not meet diagnostic criteria for a primary mental illness. The team may be projecting their own biases about religion.

 It is important to empathically consider Mrs. P’s beliefs so that Dr. J can form a trusting alliance that will enable the clinician to understand her own thoughts and feelings about Mrs. P, which are key to accurate diagnosis.

 Is there an ethical duty to reconsider the patient’s diagnosis in light of the pastor’s narrative?

 Yes, because the pastor says Mrs. P’s beliefs do not reflect those of her religious tradition and thus it is much more likely she is psychotic.

 Yes, because the pastor finds Mrs. P, whom he knows well, to be irrational. This further suggests she is delusional, and those delusions may be impairing her capacity.

 No, not because of the pastor’s interaction. There is a ethical duty to reconsider on the grounds that Mrs. P’s behavior is increasingly erratic, and she is more and more difficult to engage in care.

 No, because this is just a religious disagreement and has nothing to do with a psychiatric diagnosis.

. DR GEPPERT WILL DISCUSS THE ETHICAL CONCERNS AND QUESTIONS IN AN UPCOMING ISSUE OF 

If you were the consultant, what issues might you raise in the cases discussed here?

ETHICS QUIZ | Faith and Reason

Mr D is a 65-year-old retired mechanic with severe alcohol dependence. He has previously been admitted to local community hospitals and the regional academic medical center dozens of times for management of alcohol intoxication and withdrawal, including several episodes of delirium tremens and seizures. He is always offered inpatient substance use treatment. He agreed to residential treatment only once but left after only a few hours.

Mr D’s family, an adult son and his wife as well as a brother, are increasingly frustrated with Mr D’s multiple relapses. During this latest presentation, the son produces a durable power of attorney (POA) for health care and demands that the physicians declare his father to lack decision-making capacity, which would allow him to make medical decisions for his father. The goal is to force Mr D into residential alcohol treatment. The family confronts the attending hospitalist with Mr D’s history of multiple admissions and relapses and asks him to “explain how rational persons can drink this much unless they were trying to kill themselves.” The hospitalist requests a psychiatric consultation to evaluate Mr D’s decisional capacity and to determine whether he is suicidal.

The psychiatrist who has previously seen the patient performs a thorough assessment, including cognitive testing and a formal 

 to refuse substance use disorder treatment. Mr D shows mild impairment in working memory but scores within the normal range on a number of screens for dementia. He has no history of past suicide attempts, and avows no current ideation or intent to harm himself. Mr D does not meet criteria for any psychiatric disorder other than severe alcohol use disorder. The psychiatrist uses motivational interviewing during his assessment, and Mr D-as he has many times before-says he wants help to stop drinking but refuses to consider residential or inpatient treatment.

The psychiatrist finds that Mr D is not acutely suicidal and possesses adequate decisional capacity to decline substance use disorder treatment, and he informs the team and family of the results of his assessment. The brother asks if Mr D can be admitted against his will “for his own good.” The son adds that his POA gives him the right to make medical decisions, and he wants his father admitted to a substance use treatment program. He angrily tells the health care team and the psychiatrist, “My father is going to die from drinking and when he does, it will be your fault for not doing anything to stop him.”

Severe alcohol dependence and frequent relapses in this patient prompts his son to produce a durable power of attorney for health care. He demands that the physicians declare his father to lack decision-making capacity. More in this ethics case report.

Case Report: Drinking, Decisional Capacity, and Death

A quarter of a century ago, psychiatric ethics was a far narrower realm of discourse. Ethics education-whether in residency or practice-was mostly confined to the forensic psychiatric issues of inpatient psychia try, such as involuntary commitment and competency determinations, and the psychoanalytic sphere of concern focused on boundary crossings and violations of the psychotherapeutic frame.

The universe of psychiatric ethics has dramatically expanded as evinced in the list of potential topics the editorial staff considered for this special report (

). The order of the list does not indicate priority or importance, [[{"type":"media","view_mode":"media_crop","fid":"23239","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2100186891081","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1794","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"160","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]which is what made it so difficult to select the most appetizing topics from this rich conceptual menu. We hope during the course of the year to be able to offer up some of these fascinating subjects in print, on our Web site, and through our expert commentator blogs. A number of the issues on the list not covered in the special report were the subject of 

: results of which will also be featured in various formats in the future.

A quick glance at this expansive but far from comprehensive list of psychiatric ethics questions shows that the impact of law on psychiatry remains, as does the centrality of the physician-patient relationship. Yet this post-modern synopsis also reflects a more pervasive influence of the technological imperative, the business of medicine, the politics of being a physician, and an increasingly multicultural and aging democracy than it would 2 decades ago. The electronic information revolution in medicine and psychiatry rivals that of the scientific revolution of the 17th century and has affected almost every subject in this special report-an unprecedented phenomenon in the history of psychiatric ethics.

End-of-life ethics was long dominated by internal medicine, but Richard Martinez, MD, MH, and Casey Frank, JD, MPH, give us an impressive summary of important legal and public policy developments in the area of end-of-life bioethics where psychiatry’s presence and gifts are coming to fruition. We are excited that the substantive quality of this review enables it to serve as 

Against the backdrop of media psychiatry, cable television therapy, psychiatric blogs, and tweets about more things than Horatio ever dreamed of in his psychiatric residency, 

, examines the so-called “Goldwater Rule.” As a caution and caveat to free talking, he provides an excellent rule of thumb for those embarking on public commentary: play the role for which psychiatric professionals are well cast-that of educator of the public-and eschew the risky business of opining about the private lives of the rich and famous.

, looks at one of the most controversial developments in contemporary psychiatry: the full and real-time access of patients to their psychiatric records. Whether we think patients should read their charts, they are already doing so-another example of the democratization of psychiatric ethics. The author provides practical tools for the navigation of what is inarguably a sea change in psychiatric thinking about disclosure and reassurance that transparency in documentation does not have to be traumatic for the patient or the practitioner.

, reminds us of the philosophical birth of psychiatry with a presentation of Aristotelian virtue theory for the 21st-century psychiatrist. Virtue theory offers a value-based aspiration to ideals approach to psychiatric ethics to balance the rules-based ethics of an increasingly commercialized and regulated health care system

One area of regulation that psychiatrists, like their medical and surgical colleagues, will now be forced to master is coding and billing. DSM-V, HCA, ICD-11, and the new CPT codes, while frustrating to many in the short term, in the long haul will move us toward parity with the rest of medicine. 

, leads us through the maze of documentation details without losing the center of what we do-care for patients.

Many of the ethical dilemmas explored in these articles chart new territory in the moral imagination. The complexity and pluralism of the cultural context in which psychiatry is now embedded cast doubt on the survival of the cornerstone of psychiatry: the private psychiatric psychotherapist. Public skepticism now rivals that of the enlightenment period: neuroscience, research trials, and alternative and complementary medicine are deconstructing the psychopharmacological dominion of biological psychiatry.

Amidst this doubt and chaos, the authors of these articles provide guidance and hope that psychiatry can reinvent itself as it has so many times before to not only endure but to evolve to a new joining of our humanistic past and scientific present to create a renaissance psychiatrist of the future. So let us boldly go together where psychiatric ethics has never gone before!

Dr Geppert is Chief of Consultation Psychiatry and Ethics at the New Mexico Veterans Affairs Health Care System in Albuquerque. She is also Professor in the Department of Psychiatry and Director of Ethics Education at the New Mexico School of Medicine. She serves on the Editorial Board of

The universe of psychiatric ethics has dramatically expanded. Let us boldly go together where psychiatric ethics has never gone before! 

Introduction: The Brave New World of Psychiatric Ethics

How often are you confronted with an ethical dilemma in your clinical practice? How comfortable-and how prepared-are you to deal with these issues? Have the ethical dilemmas you face become more difficult in recent years?

Those are just a few of the questions posed in the Psychiatric Times Ethics Survey-a survey that turned out to be the largest ever of its kind: 708 psychiatrists took time to respond along with other health professionals, including nurses, psychologists, and students-for a grand total of 1400 responses. Another ethics survey is planned for later this year.

The charts you see here are randomly culled from that ethics survey. The survey included 19 questions that touched on end-of-life issues, boundary issues, confidentiality, and third-party influence.



How often are you confronted with an ethical dilemma in your clinical practice? How comfortable-and how prepared-are you to deal with these issues? Those are just a few of the questions posed in the Psychiatric Times Ethics Survey-a survey that turned out to be the largest ever of its kind.