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 Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.
How radically do we want to alter the physician’s traditional ethical obligations to the most vulnerable of patients?
It seemed incredible to me, as a psychiatric physician and medical ethicist, but this was the headline on the Medscape website: “Assisted Dying for Mental Illness, Minors Proposed in Canada.”1 Under the guise of promoting “death with dignity,” Canada may soon permit doctors to facilitate the suicide of “mature minors” with psychiatric illness causing “intolerable suffering.” The basis for this proposal is a recent report to Canadian lawmakers from the Special Joint Committee on Physician-Assisted Dying.
For many of us who have raised ethical objections to so-called physician-assisted suicide (PAS) in general,2 this proposed expansion into the realm of adolescent mental illness seems to validate the “slippery slope” argument many medical ethicists have raised. And the notion that some people with unrelenting psychiatric illness ought to be “assisted” in ending their lives is not confined to Canada. In Belgium and the Netherlands, PAS is legally permitted for cases of “unbearable suffering” due to “untreatable” mental illness-despite considerable controversy over how these terms are defined and how patients are selected. Thus, Kim and colleagues3 studied assisted suicide of psychiatric patients (N = 66) in the Netherlands, and found some disturbing trends: ie, “Consultation with other physicians was extensive, but 11% (n = 7) of cases had no independent psychiatric input, and 24% (n = 16) of cases involved disagreement among consultants. The euthanasia review committees found that 1 case failed to meet legal due care criteria.”3 Psychiatrist Dr Paul S. Appelbaum commented, “The criteria in the Netherlands essentially require that the person’s disorder be intractable and untreatable, and this study shows that evaluating each of those elements turns out to be problematic.”4
To be clear: neither medical ethics nor the US legal systems prohibit a mentally competent adult with a terminal illness from refusing “heroic” measures, such as being maintained on a ventilator. Nor does a psychiatric diagnosis by itself necessarily mean that a person is incompetent to make treatment decisions, including cessation of medical care near the end of life. So, in theory, a terminally ill adult who also has a psychiatric disorder could be competent to refuse potentially lifesaving treatment-and, in 5 American states, to request physician-assisted suicide.
However, the Canadian proposal differs from this scenario in several important respects. First, it is intended eventually to extend to so-called “mature minors”-not just adults. It is not clear how “maturity” will be determined, or what that term really means in the context of the normal adolescent’s often stormy psychological development. (In fairness, the report does recommend that the Government of Canada “. . . immediately commit to facilitating a study of the moral, medical and legal issues surrounding the concept of ‘mature minor.’”5) Second, the Canadian proposal would apply to illnesses, such as major depression or schizophrenia, that are not inherently “terminal” or “end stage”-like, say, pancreatic cancer or end-stage renal disease. On the contrary, psychiatric illnesses-even severe, refractory ones-are, in principle, still treatable.6,7 Indeed, as my colleague Dr Cynthia M. Geppert has observed, “futility” with regard to psychiatric disorders is a concept “whose time has not yet come.”6
Furthermore, while, in theory, a person with severe major depression or schizophrenia may be mentally competent to make certain treatment decisions, it is often extremely difficult to establish competence in the presence of such serious psychiatric illness. For example, the person with severe major depression who has failed to respond to 3 trials of an antidepressant may wrongly conclude, “There is no hope for me. I’m finished. My only option is suicide!” even though there are still many potentially effective remedies available. Such cognitive distortions are very common in severe-and, particularly, in psychotic-major depression, and these diminish the person’s rational assessment of treatment options. But a depressed person intent on ending his or her life may not disclose nihilistic or suicidal thoughts to a clinician-especially if he or she knows that the availability of PAS hinges on concealing them. Now, add in the normal emotional turbulence and impulsivity of adolescence. For all these reasons and more, even those who might support the concept of “physician-assisted dying” for mentally competent, terminally ill adults should be alarmed by this radical expansion of the concept.
As Dr Appelbaum stated in a recent JAMA editorial: for patients in severe pain with demonstrably terminal medical illnesses, such as metastatic cancer:
. . . the application of the criteria for assistance [in dying]. . . while not easy in every case, is relatively straightforward. For psychiatric patients, however, for whom a desire to die is often part of the disorder and whose response to additional treatment is less certain, the competence of their decision and the intractability of their suffering are much more difficult to assess.8
This is not a debate about whether mentally competent adults ought to be at liberty to end their own lives when faced with an intractably painful, terminal illness.2 Nor is it even a debate about the general concept of “physician-assisted dying.” It is really about how radically we want to alter the physician’s traditional ethical obligations to the most vulnerable of patients: adolescents with serious but treatable mental illnesses who want to end their lives. I do not believe our response should involve colluding with their wish for death-and I hope Canadians will ultimately reach the same conclusion.
This article was originally posted on 4/20/2016 and has since been updated.
Note to readers: As with all of our content, the opinions expressed here are solely those of the author. Comments not followed by full names and academic titles will either be removed or heavily monitored. –Psychiatric Times
Dr Pies is Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston, and Editor in Chief Emeritus of Psychiatric Times.
1. Melville NA. Assisted dying for mental illness, minors proposed in Canada. Medscape. March 11, 2016. http://www.medscape.com/viewarticle/860237. Accessed April 6, 2016.
2. Pies R. Merciful assistance or physician-assisted killing? Psych Central. September 30, 2012. http://psychcentral.com/blog/archives/2012/09/30/merciful-assistance-or-physician-assisted-killing/. Accessed April 6, 2016.
3. Kim SH, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. Published online February 10, 2016. doi:10.1001/jamapsychiatry.2015.2887.
4. Carey B. Assisted suicide study questions its use for mentally ill. New York Times. February 11, 2016. http://www.nytimes.com/2016/02/11/health/assisted-suicide-mental-disorders.html?_r=0. Accessed April 6, 2016.
5. Special Joint Committee on Physician-Assisted Dying. Medical assistance in dying: a patient-centered approach. https://www.documentcloud.org/documents/2721231-Report-of-the-Special-Joint-Committee-on.html. Published February 2016. Accessed April 6, 2016.
6. Geppert CM. Futility in chronic anorexia nervosa: a concept whose time has not yet come. Am J Bioeth. 2015;15:34-43.
7. Pies RW. Anorexia nervosa, “futility,” and category errors. Am J Bioeth. 2015;15:44-46.
8. Appelbaum PS. Physician-assisted death for patients with mental disorders-reasons for concern. JAMA Psychiatry. Published online February 10, 2016. doi:10.1001/jamapsychiatry.2015.2890.