Wednesday, October 27, 2021

Assisted suicide and the autonomy myth. Do patients really have rational autonomy?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr's Ronald Pies and Cynthia Geppert are psychiatrists and ethicists who are challenging the ethos of autonomy related to assisted suicide. For the past several years Pies and Geppert have argued in an academic account that autonomy is a myth with assisted suicide.

Pies and Geppert published an article in July 2018 titled: Two misleading myths regarding medical aid in dying where they challenged the concept that assisted suicide was an act of autonomy.

On October 27, Pies and Geppert were published in the Psychiatric Times with a further development of their position in an article titled - Physician Assisted Suicide and the Autonomy Myth. In their current article they recap their previous position regarding assisted suicide and autonomy but then develop it further. They state:
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.” 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.)
Pies and Geppert examine research related to rational autonomy, authentic voluntarism, approach to the patient and then they conclude:
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, psychiatrists should also be aware of the subtle cognitive and emotional issues that compromise rational autonomy in the context of terminal illness.
I have argued a similar approach to the same issue, that assisted suicide laws are not about autonomy. With current assisted suicide laws, the person who approves assisted suicide, can be the same person who carries out the act, and is the same person who reports the act (or fails to report the act) to the government body. This self reporting system is designed to give the physician, the right in law, to approve, carry-out and potentially cover-up abuse of the law. This system is not conducive to autonomy but rather to protecting physicians who cause the death of their patients.


Ronald W. Pies MD said...

Many thanks for the kind call-out to our article, Alex...much appreciated, and I hope it does some good!

Best regards,
Ron Pies MD

Tershia said...

Moreover, in Canada vulnerable sick and suffering people are manipulated by the government into accepting PAS/MAID, as in doing so they are benefiting the common good of society - meaning they will no longer be a financial burden to the government.

Sadly, in my experience some churches don’t care about this either. They declined to show the last video I made available to them, and instead returned it to me. On the other hand, Christians may not minister to vulnerable people under the law forbidding “proselytizing “

Ron Panzer said...

So true!

Ron Panzer

Mark Komrad MD said...

My summary of the article:

This is one of the more important papers to recently address a key flaw in arguments for physician assisted suicide and Euthanasia. One of the chief arguments in favor of permitting these procedures is based on the notion of autonomy.

Pies and Geppert deftly challenge the idea that there is true autonomy for patients seeking Physician administered death. They note that it is more about “Physician Autonomy“ than the patient’s, as it is the physician who ultimately decides to provide or deny the procedure, in the end trumping the patient’s autonomy. Indeed, the patient cedes their autonomy to the physician, making this “heteronomy,” not autonomy.

They also explore other cultural models of “autonomy” besides the western mainstream one, and observe that autonomy seems to have crowded out other vitally important values in medical ethics in this context.

They also point to the way assumptions about the patient’s autonomy may be quite flawed and require a far deeper investigation than a brief capacity assessment (even that is a specialized skill which most physicians, even non-forensic psychiatrists, do not possess). True autonomy in this context —for which they use the term “authentic volunteerism” — means freedom from the hopelessness, despair, alienation, and cognitive distortions that serious illness can produce. These “internal coercions” they explain, add to “external coercions” e.g. from a family that may stand to gain (practically or emotionally) by a patient’s death, poverty, etc.

Also as seasoned psychiatrists, the authors observe 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…. 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.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”

Significantly, lethal prescriptions for assisted suicide May sit around unused for weeks, months, even a couple of years. Meanwhile the patient’s capacity and autonomy may have deteriorated in that time. However, no jurisdiction requires that it be reassessed prior to such delayed use.

Current statues, procedures, clinical training and time constraints all lead to failure to provide the kinds of guidelines, investigations, witnessing and evaluation that would ensure that true autonomy or “authentic volunteerism” is present. This article shows how the notion of “autonomy” deployed in support of assisted suicide and euthanasia —is a vacuous shibboleth.

Mark S. Komrad M.D., DFAPA
Faculty of Psychiatry, Johns Hopkins, Tulane, and University of Maryland

Unknown said...

The depression that fuels the desire ti die is without a doubt complex with a plethora of reasons. We often forget that tbose who commit suicide almost always have a rationale that is logical to the person. But that does not mean the decision is viable; it almost never is.
The act of promoting or even witnessing the death of another human being is also affectual, even in justifiable circumstances. This is PTSD. We have seen the effects among combat soldiers, but also recently in the pandemic with doctors and nurses who have not been able to weather the adverse number of deaths. Being able to advance death is not the solution as it will accelerate the onset. Only the cold hearted can not be affected, and then it becomes a lack of discriminatory value on life, and that leads to those who kill pathologically. Just because a doctor may have a degree and a gang member/ hitman does not, the brain physiology / rational complacency and reasoning from frequency are one and the same. Legal does not change human nature.

Dcn William Gallerizzo, MBe