Against Assisted Suicide

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

FROM OUR READERS

We would like to respond to the article "A New Question in End-of-Life Ethics" by Strouse, Battin, Bostwick, et al.1 Their article in turn addresses an earlier essay on suicidal ideation and behavior in oncology patients.2

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.

What Is Legal vs What Is Right

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 fact-value distinction. 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.”3

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.”4 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.5 Furthermore, in Washington v. Glucksberg (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 medical aid in dying fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term physician-assisted suicide/PAS.6 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 aid in dying and elected to retain the term physician assisted suicide in all AMA documents and references.7 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 Sulmasy3 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.”8 Similarly, suicide rates in the Netherlands (where medical euthanasia is legal) have accelerated, compared to neighboring countries that have not legalized medical euthanasia.9

Taking One’s Own Life is Suicide

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 suicidium—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.

As philosopher Gerald Dworkin, PhD, has put it10:

[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 assisted dying have replaced the more troubling ordinary language term assisted suicide.11 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 ambivalence of many physicians who carry out MAID has been well-documented.12

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 chooses MAID, is not required by state laws to undergo the treatment.13 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.”14 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.”6

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 certifying competency for PAS.15

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.”3,16 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 out14:

[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.

The Precautionary Principle

Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories of physician aid in dying and conventional suicide.17 Accordingly, we believe that the same precautionary principle that governs public health ought to apply to MAID requests.18

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 prescribed lethal medication were referred for psychiatric evaluation.19

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.20

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 dying17: “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 note: “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.”21 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.22 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.

Concluding Thoughts

The American College of Physicians has said23:

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 Leon Kass, MD, has pointedly cautioned: “We must care for the dying, not make them dead.”24

Dr Pies 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 Psychiatric TimesTM (2007-2010). Dr Komrad 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. Dr Geppert 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 Psychiatric TimesTM. Dr Hanson is Director, Forensic Psychiatry Fellowship, University of Maryland, Baltimore, MD.

References

1. Strouse T, Battin MP, Bostwick MJ, et al. A new question in end-of-life ethics. Psychiatric Times. June 11, 2021. Accessed June 20, 2021.

2. Myers CJ, Retamero C. Suicidal ideation and behaviors in oncology patients. Psychiatric Times. 2021;37(8).

3. Sulmasy DP. Physician-assisted suicide and the perils of empirical ethical research. JAMA Netw Open. 2019;2(8):e198628.

4. Myers v Schneiderman, 30 1 NY Court of Appeals (2017).

5. Morris v Brandeburg, 376 836 NM Supreme Court (2016).

6. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide. Ann Intern Med. 2018;168(11):834-835.

7. Sabin J. Opinion of the council on ethical and judicial affairs. Proceedings of the 2019 Annual Meeting of the American Medical Association. 2019:235. Accessed June 23, 2021.

8. Jones DA, Paton D. How does legalization of physician-assisted suicide affect rates of suicide? South Med J. 2015;108(10):599-604.

9. Boer T. Does euthanasia have a dampening effect on suicide rates? Recent experiences from The Netherlands. Journal of Ethics Mental in Health. 2017;10:1-9.

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". HEC Forum. 2013;25(4):345-359.

12. Pies RW. How does assisting with suicide affect physicians? The Conversation. 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. Cogn Behav Pract. 2014;21(4):404-415.

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. N Engl J Med. 2013;368(15):1417-1424.

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. Int J Occup Med Environ Health. 2004;17(1):43-46.

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. J Clin Psychiatry. 2018;79(6):18lr12566.

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. NCHS Data Brief. 2020;(362):1-8.

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. Ann Intern Med. 2017;167(8):576-578.

24. Kass LR. Dehumanization triumphant. Conn Med. 1996;60(10):619-620

Further reading

Canetto SS, McIntosh JL. A comparison of physician-assisted/Death-with-Dignity death and suicide patterns in older adult women and men. Am J Geriatr Psychiatry. June 11, 2021. Accessed June 23, 2021.

Komrad MS. Are physicians who assist in suicide betraying their professional values? Psychiatric Times. June 15, 2021. Accessed June 23, 2021.

Pies RW, Hanson A. Twelve myths about physician assisted suicide and medical aid in dying. HCP Live. July 7, 2018. Accessed June 23, 2021. https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide