Two Misleading Assisted Suicide Myths

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

Dr Cynthia Geppert

The Journal, Psychiatric Times, published an insightful article on July 18 titled: Two Misleading Myths Regarding "Medical Aid in Dying" written by Cynthia M. A. Geppert, MD, PhD, MPH and Ronald W. Pies, MD examing issues of autonomy and the definition of terminal illness.

Based on the first question the authors examine the traditional definition of autonomy and write:

Even a casual perusal of most MAID/PAS legislation—modeled closely on the 1997 Oregon “Death with Dignity” statute—reveals that these 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.

Of course, there is much more at stake in this debate than mere procedural autonomy (ie, the ability to “command and control” a particular sequence of events or procedures). At issue is what we would call authentic autonomy, which reflects both the psychology and the core internal values of the person. How, then, is the patient’s authentic autonomy assessed under current PAS statutes? To what degree is the patient’s genuine informed consent ensured? And are there sufficient safeguards under current PAS statutes to ensure that the patient does not have a psychiatric disorder that would impair understanding and undermine informed consent? Can a person in such existential distress truly exercise the voluntarism that is integral to authentic autonomy? We believe that, under current MAID/PAS regulations, these critical issues have not been given serious moral consideration.

Dr Ronald Pies

The authors then evaluate the concerns related to depression and mental illness and they state:

Furthermore, it is not true that under current PAD statutes “. . . mental illness that would affect the rationality of decision-making is screened out,” as erroneously claimed in a position paper from the American Association of Suicidology. One of the most profound and misunderstood limitations of statutes modeled after the Oregon Death with Dignity Act is that they do not require examination by a mental health professional, except when the participating physician is “concerned” and decides to do so. In fact, in Oregon, 204 patients were prescribed lethal drugs in 2016 under the “Death with Dignity” statute, yet only 5 patients were referred for psychiatric or psychological evaluation.

They then conclude their concerns by outlining how assisted suicide laws do not ensure autonomy:

Rather, current PAS statues create a superficial “pseudo-autonomy” that is, at best, cosmetic in nature. Procedural boxes may be checked, but the underlying conscious and unconscious motives of those involved are virtually ignored. In particular, the role of transference, countertransference, and coercion in PAS decisions has been sorely neglected, as have the unconscious fears and fantasies of the patient requesting PAS. Indeed, “. . . coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide.”

The second misleading myth that the authors examine is the definition of terminal illness. The authors examine how the terminal illness has been re-defined in Oregon:

Most PAS legislation applies to an adult with a terminal illness or condition predicted to have fewer than six months to live. The common interpretation of this phrase would be, “six months to live even with treatment,” often with the assumption that there is no further or additional therapy capable of halting or reversing the disease process. Good law and sound public policy both depend upon clear and cogent definitions. Yet, incredibly, “terminal illness” is never defined at this level of detail in existing PAS statutes (ie, with respect to treatment vs no treatment). Nevertheless, in Oregon and Washington State, nearly identical criteria are interpreted to mean fewer than six months to live without treatment. Thus, an otherwise healthy 20-year-old with insulin-dependent diabetes could be deemed “terminal” for the purpose of Oregon’s “Death with Dignity Act,” since, without insulin, the patient would probably die within six months.

So, too, patients refusing appropriate treatment may be deemed “incurable” or “terminal” under current interpretation of the Oregon law. Thus, a patient with anorexia nervosa who refuses treatment could be eligible for PAS under Oregon law, even though she has never tried a course of intensive, evidence-based therapy. By this Orwellian logic, an individual with pneumonia who refuses to take antibiotics could be deemed “incurable” and qualify for physician-assisted suicide!

The authors then examine the communication between Craig New, Research Analyst with the Oregon Health Authority and Fabian Stahle, a Swedish investigator. The authors write:

In a remarkable, notarized exchange with the Oregon Health Authority, Mr. Stahle posed the following questions:

In the [Oregon] law, “terminal disease” is defined as an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment (in the opinion of the patient’s attending physician and consulting physician), produce death within six months. Is this rule interpreted as “without administration of life-sustaining treatment”?

Craig New, ... replied as “ . . . your interpretation is correct. The question is: should the disease be allowed to take its course, absent further treatment, is the patient likely to die within six months?” [emphasis added]

Stahle then posed a follow-up question to Mr. New:

If a patient with a chronic disease (for instance, diabetes) by some reason decides to opt out from the life-sustaining medication/treatment and by doing so is likely to die within 6 months, thereby transforming the chronic disease to a terminal disease—does he/she then become eligible to take use of the act?

New replied that, yes, indeed—the patient would qualify for assisted suicide. In New’s words, the Death With Dignity Act “. . . does not compel patients to have exhausted all treatment options first, or to continue current treatment . . . [and] if patient's decide they don’t want treatment, that is their choice.”

The authors then conclude their article by stating:

There is certainly room for debate regarding the role of the physician in “end-of-life” care. Nonetheless, as psychiatrists and medical ethicists, we believe that so-called “medical aid in dying” (physician-assisted suicide) is a serious boundary violation and an unethical act. This is consistent with the historical positions of the American Medical Association, the American Psychiatric Association (based on the AMA Code of Ethics), the American College of Physicians, the World Medical Association, and the American Nurses Association.

Whatever individual physicians decide with respect to MAID/PAS, it must be based on a clear-eyed understanding of current statutes and legislation. This means exposing the myths that surround these statutes. Among these are the commonly-received notions that patients choosing PAS act “autonomously” and have a demonstrably incurable condition. In truth, current PAS statutes produce a form of pseudo-autonomy that enshrines the supreme authority of the physician, and re-defines “incurable” to mean almost anyone who is seriously ill.

Thank you to Cynthia M. A. Geppert, MD, PhD, MPH and Ronald W. Pies, MD for examining these issues in a clear and direct manner.