A New Question in End-of-Life Ethics

Thomas Strouse, MD

Dr Strouseis Maddie Katz Professor of Palliative Care Research and Education at the UCLA David Geffen School of Medicine, where he is Vice Chair for Clinical Affairs in the Department of Psychiatry. He is Board Certified in Psychiatry and Hospice/Palliative Medicine.

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Margaret Battin, PhD

Dr Battin is Distinguished Professor of Philosophy and Medical Ethics at the University of Utah. She has authored, co-authored, edited, or co-edited some twenty books, including two collections on end-of-life issuesThe Least Worst Death and Ending Life; and a comprehensive sourcebook, The Ethics of Suicide: Historical Sources. She has been named one of the “Mothers of Bioethics.”

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J. Michael Bostwick, MD

Dr Bostwick is professor of psychiatry at the Mayo Clinic.

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Lewis M. Cohen, MD

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Elizabeth Morrison MD

Dr Morrison has been in the private practice of general and forensic psychiatry for over 35 years. Active in the American Psychiatric Association at both national and local levels, she is past president of Washington Psychiatric Society.

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Stuart Youngner, MD

Dr Youngner is a professor of bioethics and psychiatry in the School of Medicine, Case Western Reserve University.

Patients with terminal illnesses may choose to refuse treatment or even hasten their own deaths, but is that the same thing as suicide?

FROM OUR READERS

We read with interest “Suicidal Behaviors and Ideation in Oncology Patients” by Carey J. Myers, MD, PhD, and Carolina Retamaro, MD.

We understand that the authors focused on assessments for psychopathology and suicide risk in patients undergoing disease-directed cancer treatments. In the section “Is Refusal of Treatment a Form of Suicide?” they touch on the concept that (consistent with long-held personal health values and in the absence of contributing psychiatric illness) some patients may choose to refuse—or start and eventually discontinue—disease-modifying therapies with the aim of letting their disease take its natural course, even though that might hasten death. What they do not explore are more active forms of hastening death.

We wish to address this omission. Ten states and the District of Columbia, representing roughly 22% of the United States population, have now legalized Medical Aid in Dying (MAID). While Myers and Retamaro do not directly raise the relationship between cancer suicides and MAID, we believe it important enough to pen a response.

Data from MAID-permitting states shows that patients whose advanced malignancies are likely to lead to their deaths within 6 months comprise the vast majority of those pursuing MAID: 70% to 80% of MAID deaths involve terminal cancer.1-3 Broadly, MAID laws allow terminally ill adults with decision making capacity to request and receive from a willing prescriber a lethal prescription to self-administer at the time of their choosing. All current state laws explicitly stipulate that such deaths are not suicide. The District of Columbia statute, for example, asserts that, “actions taken in accordance with this act do not constitute suicide, assisted suicide, mercy killing, or homicide.”4 Maine’s statute adds that state reports may not refer to acts committed under this Act as suicide or assisted suicide,5 and Washington State’s statute instructs that “state reports shall refer to practice under this chapter as obtaining and self-administering life-ending medication.”6 Such stipulations guide how to understand the practice, how to complete death certificates, and how to prevent insurers from refusing to pay death benefits. Most importantly, they are intended by lawmakers to help avoid the stigma of suicide.

A large and growing literature outlines the differences between decisions to decline disease-modifying treatments (or directly hasten one’s own death) and the psychopathology associated with suicidal behavior.7-10 The latter may trigger efforts at suicide prevention and intervention, sometimes even against an individual’s will.11 And while cases with characteristics of both conventional suicides and MAID do occur, clinicians must be prepared to distinguish between them in order to respond appropriately.12

This does not challenge the undeniable fact that some cancer patients die by (conventional) suicide. We simply argue that MAID is not the same as those deaths.

We recommend that professionals in jurisdictions with MAID familiarize themselves with relevant statutes, and that terminally ill oncology patients receive accurate information about their rights under the law. Together with accurate predictions about prognosis and expected outcomes of available treatments, this information is essential for physicians who want to work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.

Dr Strouse is Maddie Katz Professor of Palliative Care Research and Education at the UCLA David Geffen School of Medicine, where he is Vice Chair for Clinical Affairs in the Department of Psychiatry. He is Board Certified in Psychiatry and Hospice/Palliative Medicine. Dr Cohen is an emeritus professor of psychiatry at Tufts University School of Medicine and an emeritus professor of psychiatry at the University of Massachusetts-Baystate Medical School. He is the author of A Dignified Ending (Rowman & LIttlefield, 2019), and a Guggenheim fellow in Health & Medicine. Dr Youngner is a professor of bioethics and psychiatry in the School of Medicine, Case Western Reserve University. Dr Battin is Distinguished Professor of Philosophy and Medical Ethics at the University of Utah. She has authored, co-authored, edited, or co-edited some twenty books, including two collections on end-of-life issuesThe Least Worst Death and Ending Life; and a comprehensive sourcebook, The Ethics of Suicide: Historical Sources. She has been named one of the “Mothers of Bioethics.” Dr Morrison has been in the private practice of general and forensic psychiatry for over 35 years. Active in the American Psychiatric Association at both national and local levels, she is past president of Washington Psychiatric Society. Dr Bostwick is professor of psychiatry at the Mayo Clinic.

References

1. Oregon Health Authority. Oregon death with dignity act. February 26, 2021. Accessed June 10, 2021.

2. California Department of Public Health. California end of life option act 2019 data report. July 2020. Accessed June 10, 2021.

3. Washington State Department of Health. 2018 death with dignity act report. July 2019. Accessed June 10, 2021.

4. District of Columbia Law 21-182(16). Death with Dignity Act of 2016.

5. LD 1313(HP 948). An Act to Enact the Maine Death with Dignity Act.

6. 70.245.180(1). The Washington Death with Dignity Act.

7. Puts MT, Tapscott B, Fitch M, et al. A systematic review of factors influencing older adults' decision to accept or decline cancer treatment. Cancer Treat Rev. 2015;41(2):197-215.

8. Strouse TB. Requests for PAD and the assessment of capacity. Hastings Cent Rep. 2019;49(1):4-5.

9. Cohen LM, Steinberg MD, Hails KC, et al. Psychiatric evaluation of death-hastening requests. Lessons from dialysis discontinuation. Psychosomatics. 2000;41(3):195-203.

10. Yager J, Ganzini L, Nguyen DH, Rapp EK. Working with decisionally capable patients who are determined to end their own lives. J Clin Psychiatry. 2018;79(4):17r11767.

11. Bostwick JM, Cohen LM. Differentiating suicide from life-ending acts and end-of-life decisions: a model based on chronic kidney disease and dialysis. Psychosomatics. 2009;50(1):1-7.

12. Creighton C, Cerel J, Battin M. Statement of the American Association of Suicidology: “Suicide” is not the same as “Physician Aid in Dying.” American Association of Suicidology. October 30, 2017. Accessed March 30, 2021.