Should psychiatrists assist the suicide of their patients, even if it is legal?

This article was published by the Psychiatric Times on July 8, 2021

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Doctors Ronald W. Pies, MD, Mark S. Komrad, MD, Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS, and Annette Hanson, MD tackle the difficult question in the Psychiatric Times, that being should psychiatrists assist the suicide of their patients, even if if is legal?

All of the writers have been published on issues concerning their professional obligations and why psychiatrists should never participate in assisted suicide, but now they have written about a more nuanced questions concerning the participation in acts of suicide.

This article is a response to the article "A New Question in End-of-Life Ethics" by Strouse, Battin, Bostwick, et al. Their article in turn addresses an earlier essay on suicidal ideation and behavior in oncology patients.

The response by Pies et al breaks down their concerns into several key issues.

Dr Ronald Pies

The first issue is - What is legal vs what is right. Pies et al state:

The mere fact that some state legislatures have passed statutes redefining suicide, such that MAID is not suicide, does not prove that this redefinition is conceptually or ethically justified...

While redefining suicide averts legal liability for physicians providing MAID, it does not change the essentially unethical nature of the act itself. The term medical aid in dying fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term physician-assisted suicide/PAS. Perhaps even more significant, following a comprehensive evaluation by the Council on Ethical and Judicial Affairs, the American Medical Association (AMA) House of Delegates rejected the term aid in dying and elected to retain the term physician assisted suicide in all AMA documents and references. Indeed, the process typically described as MAID in no sense aids dying; on the contrary, it rapidly converts an ill individual into a dead one. This is substantively different than the withdrawal of heroic but nonbeneficial or inappropriate measures, such as the use of ventilators that merely prolong the dying process in the final stages of a terminal illness.

Finally, statutorily declaring that self-induced death via a physician’s assistance is not suicide may soothe the consciences of legislators and allow payouts on life insurance policies; but, perversely, it may also incentivize some terminally ill patients to kill themselves.

Dr Annette Hanson

Pies et al then clarify that Taking One's Own Life is Suicide:

Redefining suicide to exclude PAS in the context of terminal illness represents a radical linguistic maneuver that flies in the face of ordinary language, expressed over thousands of years. The Latin suicidium—from which the English word suicide is derived—means the act of killing oneself intentionally or voluntarily. To be clear: we do not deny that there are often psychological and motivational differences between those with terminal illnesses who take their own lives and those who do so in the context of severe psychiatric illness, as the AAS statement details. But in both instances, the act is that of suicide.

As philosopher Gerald Dworkin, PhD, has put it

[A] s a philosopher, I feel an obligation to point out that, as a conceptual matter, there is nothing inaccurate or false about stating that a person who takes a drug, knowing that it will cause her death, and takes it because it will cause her death, is committing suicide on any reasonable conceptual analysis of what suicide is.

Dr Mark Komrad

They then discuss the issue of patients with Cognitive Distortions, who are not mandated to accept treatment:

Furthermore, most MAID laws do not require treatment for serious medical conditions, even when it is available to the patient. For example, a patient whose metastatic cancer stands a reasonably good chance of remission with aggressive treatment, but who nevertheless chooses MAID, is not required by state laws to undergo the treatment. Choosing assisted suicide in such a scenario may superficially appear to be a rational choice; but may instead represent a decision grounded in certain cognitive distortions that also characterize so-called conventional suicide. Importantly, this may be so, even in the absence of a diagnosed psychiatric disorder.

For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, noted that some cancer patients may make erroneous assumptions, like, “No one can help me” or “No one understands what I am going through.” Such cognitive distortions may respond favorably to cognitive behavioral interventions and potentially avert or abort a request for PAS. Indeed, it has been found that “Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided.”

Unfortunately, in almost every US jurisdiction where PAS is allowed, no attempt to offer treatment by a mental health professional is required by law; and the psychiatrist’s role is typically relegated to ruling out mental illness and certifying competency for PAS.

Dr Cynthia Geppert

They then discuss why the Issue is not about intractable pain and suffering:

As Daniel P. Sulmasy, MD, PhD, noted, “Despite public arguments that PAS is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control.” These are forms of psychological distress which, in our view, are best managed with supportive and empathic counseling and/or cognitive behavioral interventions, provided to patients and their families—not by prescribing lethal drugs.

They then discuss the often forgotten but essential - Precautionary Principle:

This means erring on the side of caution and treating MAID requests from patients with terminal illnesses with the same degree of psychiatric scrutiny and concern that we would bring to any patient’s expressed wish to die. However, in most states, psychiatric assessment is not mandated in the MAID process and does not occur unless specifically requested by the evaluating physician who has initiated the MAID process.. This rarely happens. For example, in Oregon in 2020, only 0.8% of patients who were prescribed lethal medication were referred for psychiatric evaluation.

Moreover, the fairly subtle cognitive distortions described by Levin and Applebaum are unlikely to be detected in a superficial assessment of mental competence. It is no contradiction or paradox to argue, as we have, that pronouncing a patient qualified or competent for MAID is a violation of psychiatric ethics, since this unethically colludes with the process of aiding a patient’s suicide. Psychiatric involvement in end-of-life care is indeed essential, but it should remain well outside the procedures and processes involved in MAID deliberations.

They then discuss the stigma of suicide and how assisted suicide shifts it to "other" suicides:

Indeed, as numerous suicide prevention websites note: “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.” We would suggest that the same may be said of at least some individuals with cancer who seek MAID. Whenever complex ethical dilemmas are formulated as black-and-white categories, the many grey instances are often misclassified, with tragic consequences.

In short, the AAS position may have the perverse effect of merely shifting societal stigma from one group—those with terminal medical conditions—to those whose suicidal behavior occurs in the context of psychiatric disorders. We do not need such a 2-tiered classification, in which there are good and bad methods of taking one’s own life.

...We believe that efforts to promote MAID would be better directed toward destigmatizing the mental illnesses that underlie the majority of suicides and toward bolstering the availability of state-of-the-art palliative care.

Pies et al then conclude their article with the following statement:

Physician-assisted suicide is neither a therapy nor a solution to difficult questions raised at the end of life. On the basis of substantive ethics, clinical practice, policy, and other concerns, the ACP does not support legalization of physician-assisted suicide. … However, through high-quality care, effective communication, compassionate support, and the right resources, physicians can help patients control many aspects of how they live out life's last chapter.

More articles on this topic:

• Psychiatrists must prevent suicide not provide it (Link).
• 12 myths about assisted suicide and medical aid in dying (Link). 
• Psychiatrists prevent assisted suicide not provide it (Link). 
• Euthanasia and physician-assisted suicide are unethical acts (Link).