Tuesday, May 12, 2020

Conceiving the inconceivable: assisted suicide for people with mental illness.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition


Thank you to Dr Mark Komrad for sharing this superb paper by Bernardo Carpiniello published in the Journal of the Italian Society of Psychiatry. Carpiniello works in the Department of Medical Sciences and Public Health-Unit of Psychiatry, University of Cagliari Italy.

Carpiniello's paper - Conceiving the unconceivable: ethical and clinical concerns over assisted suicide for people with mental disorders is a significant paper dealing with the concerns related to euthanasia for psychiatric reasons. 

Carpiniello recognizes that only a few jurisdictions in the world have legalized euthanasia and assisted suicide and in these jurisdictions only a small number of these deaths done to people with mental illness. 

Carpiniello points out that only 34% of Dutch physicians will participate in euthanasia for mental disorders.

Polling data indicates that there is more opposition by Dutch psychiatrists to psychiatric euthanasia with 53% of psychiatrists opposed to euthanasia for mental illness in 1995 and 63% in 2015. He suggests that the drop in support for psychiatric euthanasia is related to moral distress. He states:

Euthanasia or assisted suicide represents a typical example of a situation in which psychiatrists are faced with the impossibility of having to reconcile two moral obligations, a duty of care and respect of patient autonomy. To put it bluntly, for many psychiatrists euthanasia is ethically unacceptable, particularly as the main aim of psychiatry is to limit patients’ suffering.
Carpiniello then points out the position of the American Psychiatric Association.
“the American Psychiatric Association, in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death”
Carpiniello expresses his concern for the growth of euthanasia in countries where it is legal.
Euthanasia has been reported as a typical example of the “slippery slope, down which we have rolled to now allow something that was impossible to conceive as ever being acceptable”
Based on the increase in the number of euthanasia deaths and the expansion of acceptable reasons for euthanasia, I agree that incremental extensions will occur, if legalized.


Carpiniello tackles the question of suicide prevention, a primary public health concern. He quotes from the WHO Director-General, Tedros Adhanom Ghebreyesus stated:
“despite progress, one person still dies every 40 seconds from suicide. Every death is a tragedy for family, friends and colleagues. Yet suicides are preventable. We call on all countries to incorporate proven suicide prevention strategies into national health and education programmes in a sustainable way”
Carpiniello indicates that suicide prevention and suicide assistance are irreconcilable.
Indeed, an emphasis on suicide prevention from a public health perspective seems to be somewhat hard to reconcile ...for those countries simultaneously equipped with social and health policies established for the specific purpose of preventing suicide. Considering the specific role of psychiatry in preventing suicide, put in very simple terms the question is: what is the point of psychiatrists trying in every way possible to prevent suicide if the person concerned is entitled by law to seek assistance to commit this action?
Carpiniello examines the clinical concerns related to psychiatrists approving euthanasia. He points out:
“assessments of competency, sustained wish to die prematurely, depressive disorder, demoralization and ‘unbearable suffering’ in the terminally ill are clinically uncertain and difficult tasks ... As yet psychiatry does not have the expertise to ‘select’ those whose wish for hastened death is rational, humane and ‘healthy’
He explains that there are no objective measures to determine if someone has lasting or unbearable suffering.

Further to that Carpiniello finds that it is impossible to determine if treatment is futile for the patient. He states:

How can we confirm that a single case should definitely be considered untreatable if “there are no universal standards defining incurability in most cases of mental illness” and “there is no reliable mechanism to define incurable disease and determine medical futility for psychiatric care
He points out that there is no definition for the condition known as treatment resistant depression (TRD). He states:
it could prove an arduous task, even for the most experienced psychiatrist, to confirm that the case undergoing evaluation for assisted suicide is an actual TRD, ...Accordingly, it should be kept in mind how approx. 20% of Dutch patients requesting euthanasia had never undergone psychiatric hospitalization, 56% had refused some form of recommended treatment, and how in 27% of cases patients had requested assistance with dying from a physician who had not previously been involved in their treatment.
He continues by quoting from a study indicating that the majority of TRD patients get better.
More recently, 155 TRD patients were evaluated over a 1-7 year (median 36 months) follow-up, revealing how 39.2% of follow-up months were asymptomatic and 21.1% at sub-threshold symptom level, while 15.8% featured a mild, 13.9% moderate, and 10.0% severe depressive episode level, thus demonstrating how the majority of patients with TRD manage to achieve an asymptomatic state.
Further to that, he shows how there is no standard to assess competence or decisional capacity amongst these patients. He quotes from a study that was based on information from the Dutch Regional Review Committees that found:
in their evaluations physicians frequently stated that psychosis or depression did (or did not) affect capacity but provided little explanation to corroborate their opinions. The findings of this study once again raised a series of doubts as to the reliability of evaluation of decisional capacity of patients requesting EAS, at least in the Netherlands.
He then examines the phenomenon of transference and countertransference that exists in a therapeutic relationship with a patient and he states:
Some authors have criticized the assumption according to which a physician will always act in the interests of their patients, mostly because it fails to consider the doctor’s unconscious, and at times conscious, desire for the patient to die and alleviate distress for all concerned, including the physician. ...Doctors who are affected by countertransference or who have psychologically committed themselves to PAS may be prone to accepting patients’ reasons for PAS at face value without thorough exploration”
He then explains how physician/patient relationships can lead to pseudoempathy. He states:
One of the most frequently cited consequences of countertransference is over-identification with the patient, giving rise to a so-called ‘pseudoempathy’, a condition resulting in the physician experiencing the feeling that the patient’s suicidalwish is ‘normal’ and that they would feel the same way.
Carpiniello examines what he calls, the undesiralbe consequences of assisted suicide. He sites several concerns including:
  • “... will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients? If so, how far will the influence of that belief spread?”
  • data from the Netherlands, reports “56% of cases in which social isolation or loneliness was important enough to be mentioned in the report”, arguing that “the latter evokes the concern that physician assisted death served as a substitute for effective psychosocial intervention and support”
  • EAS in psychiatric patients may be detrimental in the advancement of research and implementation of new treatments, given that it “may reinforce poor expectations of the medical community for mental illness treatment and contribute to a relative lack of progress in developing more effective therapeutic strategies” 
  • “What consequences on social representations of mental illnesses, on how to deal with a mental illness and on professional profile if psychiatrists recognize that life with mental illness – even if “only” in individual cases – is not worth living?
Carpiniello concludes that no firm conclusions can be drawn based on data related to euthanasia for psychiatric reasons.

Carpiniello's paper clearly indicates that the negative consequences related to euthanasia for mental disorders suggest that this should not be done.

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