Psychiatrist: Assisted suicide - More than meets the eye.

By Alex Schadenberg

Executive Director - Euthanasia Prevention Coalition

Dr Steven King

An article written by Psychiatrist, Dr Steven King, and published in the Psychiatric Times examines assisted suicide from a scientific point of view.

King begins his article by stating that he is not religious and he is not pro-life, that his concerns are based on science.

I am not a Catholic nor do I have any particularly strong religious beliefs. I am strongly pro–abortion rights and believe that adults should be able to marry whomever they wish regardless of gender. I also believe that it is highly unethical for physicians to impose their religious or political views on their patients and allow these to affect how they care for them. However, I do have major concerns about the RTD laws. 

My concerns are based on science, not religion. As a pain medicine specialist and psychiatrist, I believe that the already existing laws and those that have been proposed have major holes that could result in people requesting death because of potentially treatable health problems.

King examines the assisted suicide laws based on their inability to protect depressed patients.

Psychiatrists have proper concerns about making sure that no patient who requests death is allowed to die if the request is the result of a treatable mental illness such as depression. All the RTD laws seek to prevent this: they require that if the attending physicians believe a mental disorder is a potential factor in the request, they need to make a referral to a mental health specialist, usually defined in the laws as a psychiatrist or licensed psychologist. 

Any psychiatrist who has been involved in consultation/liaison psychiatry can readily recognize inherent problems in the laws. Most non-psychiatrist physicians have limited training in mental illness, so relying on them to identify such illness is a chancy proposition.

King explains why many people who ask for assisted suicide in Oregon are not being assessed for depression.

Furthermore, when it comes to terminally ill patients, there is a widespread perception that depression is normal and that there is no need to address it. The executive editor of the New England Journal of Medicine once wrote, “Dying patients who request assisted suicide and seem depressed should certainly be strongly encouraged to accept psychiatric treatment, but I do not believe that competent patients should be required to accept it as a condition of receiving assistance with suicide.” Some physicians fear that referring patients to psychiatrists and psychologists is an insult to the patients by indicating it is felt that they are considered “crazy.” A study from Oregon found that of those who died under its RTD law in 2014, fewer than 3% were referred for a mental health evaluation.

King continues by explaining that people continue to receive poor pain and symptom management, even after requesting assisted suicide.

The RTD laws also acknowledge the possibility that untreated pain can be a major factor in requests for death and seek to ensure that pain will be addressed. Again, how the laws deal with the issue is troubling. For example, the California law requires that the patient’s attending physician present “feasible alternatives or additional treatment options, including, but not limited to, comfort care, hospice care, palliative care, and pain control” [italics added]. This all sounds fine. The problem is that every study of which I am aware has shown that pain is often poorly managed, including in terminally ill patients. 

It has bothered me that many proponents of RTD laws choose to overlook this, preferring to leave the impression that this isn’t a problem and that every terminally ill person receives expert palliative care. When confronted with the evidence of the reality of deficiencies in pain management, they acknowledge it is a problem that needs to be corrected but that it shouldn’t stop the passage of RTD laws.

King continues by explaining how people who are in pain are more likely to seek suicide, but also how some of the pain killing drugs lead to a higher risk for suicide.

Another complicating factor is that not only has pain itself been associated with increased risk of suicide, but so have some of the most commonly used analgesic medications for severe pain, including opioids and antiepileptic drugs.4 Untreated pain or fear of it is far from the only reason for suicide requests but—along with a desire not to be a burden to others, fears about loss of autonomy, and depression and hopelessness—it is one of the most common.

King then explains the widespread problem of uncontrolled pain.

Pain is a widespread problem in this country. A recent study by the National Center for Complementary and Integrative Health found that over 25 million American adults reported having daily pain for at least the previous 3 months and that over 40 million experienced severe or very severe pain during that time.

King concludes:

I recently attended a debate on RTD laws, and during the question period I brought up the issue of inadequate pain management. The participants on both the pro and con sides agreed this needed to be improved, and at the end of the debate the moderator, a medical ethicist, said that this seemed to be the one thing all could agree on. Left unsaid was why states aren’t passing laws to ensure this.

The Euthanasia Prevention Coalition believes in caring for people and not killing them. Legalizing euthanasia or assisted suicide leads to abandoning of people at the most vulnerable time of their life.