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In cases of assisted suicide, do patients really have rational autonomy?
Physician-assisted suicide (PAS) continues to be a hot topic, and has been addressed recently in Psychiatric TimesTM. In discussing the topic, we last addressed the issue of “autonomy” in July 2018.1 In the ensuing 3 years, 4 states—Hawaii, Maine, New Jersey, and New Mexico—have passed statutes permitting physicians to provide lethal drugs for patients who are terminally ill and wish to end their lives. One of us (Pies) recently testified before a legislative committee in Massachusetts, where a bill permitting PAS is now being considered.2 The pace at which a growing number of states are either passing or considering PAS legislation seemed compelling enough to warrant another look at what we call “the autonomy myth” in assisted suicide.
A Brief Recap
We previously argued that most PAS statutes:
provide nothing remotely resembling ‘autonomy’ for the patient, in either the procedural or personal sense. Patients who wish to avail themselves of prescribed, lethal medication must clear a number of procedural and administrative hurdles that depend entirely on the diagnostic, prognostic, and prescriptive authority of the patient’s physician. The controlling decisions regarding the patient’s diagnosis; the need for a consultant to confirm the diagnosis; the putative ‘terminal’ nature of the illness; the completion of required certification forms; and, finally, the writing of the lethal prescription are all exercises of the physician’s autonomy.
Even refusals of a patient’s request for PAS reinforce the primary role of physician autonomy in these decisions. It is clear that, at any point in this sequence—ie, prior to dispensing of the lethal drugs—a simple act on the part of the patient’s physician could overturn the patient’s request for assisted suicide (personal communication from Annette L. Hanson, MD, October 16, 2021). In short, PAS provides no procedural autonomy for the candidate/patient. Rather, PAS legislation is an example of extreme heteronomy—ie, handing over power and authority to others.
In our prior commentary, we also pointed out that autonomy is only 1 of 4 cardinal medical values; the others include beneficence, nonmaleficence, and justice.3 It has been primarily in the past 60-70 years—since the rise of the consumer movement—that autonomy has been enshrined as the primary, if not the sole, medical value.4
Furthermore, the overly individualistic and near absolutist concept of autonomy that reigns in Anglo-American law and bioethics is historically and culturally conditioned. There are many other types of autonomy than are dreamt of in our thin philosophy. Personal autonomy does not resonate with many cultural groups that perceive themselves as vulnerable or disenfranchised. Indeed, as we have discussed elsewhere, individual autonomy is subordinate to other significant ethical values in many other ethnic and cultural groups. For example, in many traditional Native American and Latino cultures, familial or community autonomy is far more important, particularly when end-of-life decisions are involved.5
Although our earlier article cited the Georgetown Mantra of the ethical theory termed principlism, there is a growing recognition that in many of its applications—such as in the justification of PAS—it is a thin, reductionistic schema of bioethics. It largely ignores older and arguably more substantive moral-ethical frameworks, such as the duty-based (deontological) morality developed by Immanuel Kant, or Aristotle’s virtue ethics. Some critics, drawing from a feminist perspective, have criticized the dominant conceptualization of autonomy for neglecting important relational and interpersonal values.6 Crucially, as Soren Holm, DrMed, PhD, has pointed out, the Georgetown principles evolved in an American context, and may not be fully transferable to other cultures and societies.7
Finally, our previous article distinguished between genuine autonomy and pseudo-autonomy, and argued that current PAS statutes are generally not capable of assessing genuine autonomy. We noted that current PAS procedures do not systematically assess the patient’s family dynamics—including the potentially coercive influences of those who might stand to gain emotionally or financially from the patient’s death. (The recently proposed PAS bill in Massachusetts—H.2381—ostensibly provides for assessment of coercion, but only at the time of clinical evaluation.8 To our knowledge, no law includes a mechanism for evaluating the authenticity of the patient’s autonomy just prior to their ingestion of the lethal drugs.) Nor do the superficial assessments of decision-making capacity required under various PAS statutes address subtle, but important factors that can compromise genuine autonomy, such as the patient’s unconscious fears and fantasies.
With that recap in mind, we now expand our discussion of genuine or rational autonomy and the closely related concept of authentic voluntarism as explicated by Laura Weiss Roberts, MD, MA.
Rational Autonomy: A Cognitive-Emotional Dyad
Rational autonomy is much more than being able to “do as you please.” After all, an infant picking up his rattle is doing as he pleases, but he is hardly acting with rational autonomy. The latter, in our view, consists of both a cognitive and an emotional component. Cognitively, rational autonomy requires, at a minimum, that the person understands the nature, risks, and benefits of the procedure or action under consideration, and has a basic understanding of the alternatives. This component is roughly what is implied in most definitions of “decision-making capacity.”
However, this minimalist criterion fails to capture the subtle cognitive distortions exhibited by some patients who are terminally ill. For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, have noted that some cancer patients may make erroneous assumptions like, “No one can help me,” or “No one understands what I am going through.”9 Such cognitive distortions can cloud the patient’s judgment and undermine rational autonomy. These distortions may respond favorably to cognitive behavioral interventions, which may avert or abort a request for PAS. (Importantly, no current PAS statutes require any form of psychotherapy for patients seeking to end their lives via PAS.)
The emotive component of rational autonomy is more nuanced and complex, involving both an external and internal dimension. Thus, a patient facing the prospect of PAS may be feeling external pressure from family or significant others, either for or against the assisted suicide. The greater risk, of course, is when the patient is being pressured to agree to PAS, because that is a decision that irreversibly ends all other decisions on the patient’s part. Obviously, a decision regarding PAS cannot be called rationally autonomous under such coercive conditions. And to repeat: Once the patient leaves the evaluation milieu and obtains the lethal drugs, nothing in current PAS statutes ensures that the patient will be free from coercive pressures in the home or family setting.
Although external coercion is nominally addressed in some PAS statutes, what is not considered in any current PAS statute is the patient’s emotional, motivational, and psychological state, which may even more severely compromise rational autonomy. For example, in our previous article, we noted that a request for assisted suicide may mask deeper, underlying wishes or fantasies—eg, the request may be a covert plea for the physician to be more empathic about the patient’s situation, or amount to a test of whether the physician still values the patient’s life as death approaches.10
Crucially, the evaluating physician typically has neither the training nor the tools to reliably and validly assess such complex and nuanced emotional states. Moreover, cognitively-based instruments such as the MacArthur Treatment Competence Assessment Tool do not delve into subtle emotional factors that may be affecting, if not clouding, the patient’s judgment.11 As Charland et al note:12
Emotions such as hope, anger, joy, sadness, fear, and many others…often play a major role in health care decisions to consent to or refuse treatment, and consent or refusal of [PAS]…Yet at present there is no consensus or theoretical vision on how to incorporate such facts into the MacArthur model. Who decides whether hope is appropriate or not, and how do we determine this?
Proponents of PAS claim that statutes require physicians to assess and treat conditions such as major depression that may impair the patient’s capacity to make a rational decision. Yet, even if patients who are terminally ill do not meet full DSM-5 criteria for a major depressive disorder, they may nevertheless feel hopeless, demoralized, or despairing.13 Or, patients may be experiencing anticipatory grief over impending death; ambivalence regarding assisted suicide; or the fear that their loved ones, and even their physicians, will abandon them. Patients may soon come to view PAS, irrationally, as the only way out of loss, conflict, and isolation. These subtle emotional states may cloud judgment and undermine rational autonomy, yet will not be picked up by a brief, one-time, cognitively based assessment of decisional capacity.
Roberts has explicated a concept she calls authentic voluntarism, which has very strong affinities with our construct of rational autonomy. Roberts argues that voluntarism must be understood comprehensively, taking into account “developmental factors, illness-related considerations, psychological issues…cultural and religious values, and external features and pressures.”14 Each of the 4 domains Roberts identified is in some degree likely influencing the reasoning and emotions of the person seeking PAS.
Roberts noted that14
Suffering and pain due to physical or mental health problems may cause one to move toward a decision out of desperation rather than deliberateness and adherence to personal values...[furthermore], some beliefs and psychological defenses that emerge in the process of dealing with an overwhelming illness may be a barrier to perceiving and considering alternatives.
Approach to the Patient
Along with our colleagues, Mark Komrad, MD, and Annette L. Hanson, MD, we have argued that psychiatrists should not collude with competency determinations in the context of PAS evaluations.15 However, psychiatrists assuredly can assess the patient for evidence of depression, despair, hopelessness, or demoralization, as well as for subtle cognitive distortions threatening authentic autonomy and voluntarism. This need not entail a decision regarding competence to request or consent to PAS.
Furthermore, psychiatrists can recommend somatic treatments and/or supportive counseling, including cognitive remediation, for those individuals who are terminally ill and whose authentic voluntarism is in doubt. Indeed, evidence suggests that when physicians intervene and successfully address issues such as pain, depression, and other medical problems, as many as 46% of patients seeking assisted suicide will change their minds.16
In a 2007 paper on voluntarism, Geppert and her colleague, Chris Abbott, MD, MD, sketched an outline of a voluntarism assessment and recommended that psychiatrists further develop more holistic and comprehensive evaluations of voluntarism. The same work needs to be done for the assessment of rational autonomy, following the guidelines Roberts suggested.17
This essay has challenged the all-too-commonly held belief that PAS is an instantiation of a patient’s autonomy. In fact, we have argued the contrary: The entire process of PAS is critically dependent on the authority of powerful others who must approve (or veto) every decision along the way. Even more centrally, we have argued that genuine rational autonomy and authentic voluntarism are frequently undermined by subtle cognitive and emotional factors that are likely to be missed with standard, cognitively based evaluation tools. Patients who may not meet DSM-5 criteria for a mental disorder may nevertheless be experiencing hopelessness, demoralization, or despair—any of which can compromise rational autonomy and authentic voluntarism. In addition, current PAS statutes provide no mechanism for assessing external coercive influences that may drive the patient to suicide after having left the evaluation setting. In addition to the many ethical reasons to oppose PAS,18 psychiatrists should also be aware of the subtle cognitive and emotional issues that compromise rational autonomy in the context of terminal illness.
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 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 she serves as the ethics editor for Psychiatric TimesTM.
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