Psychiatrist speaks to Massachusetts legislative committee to oppose assisted suicide bill.

Dear Representative,

As a Massachusetts psychiatrist and medical ethicist, I appreciate that there are people of good will on both sides of the assisted suicide controversy. Nevertheless, I believe the bills before you (Massachusetts House 2381/ Senate 1384) are masterpieces of misleading euphemisms. They represent a betrayal of medical ethics, and a clear and present danger to our most vulnerable patients. The House bill might well be called, “An Act that Gives Legal Cover to Physicians Who Assist in Their Patients’ Suicide.”

The bill perversely re-defines suicide, exonerating physicians who act under its aegis from the charge of “assisted suicide.” As a psychiatrist for nearly 40 years, I can tell you that when a patient knowingly ingests a lethal medication with the intent of dying, that is suicide. The context of terminal illness may partly explain--but does not alter--that fact. Attempts to separate suicides into “regular” and “assisted”, based on supposed psychological differences, are not well grounded in psychiatric knowledge or experience. In short, suicide is suicide.

Furthermore, the self-administration of a lethal drug does not aid or ease the dying process: it terminates dying by terminating the patient. We have well-established medical interventions for easing a terminally ill patient’s final days, such as the discontinuation of futile life-support, and the provision of state-of-the art palliative care. Lethal drugs don’t ease dying—they merely open the gateway to death.

And contrary to a popular myth, most patients requesting assisted suicide are not experiencing extreme bodily suffering, or excruciating and intractable pain. Data from Oregon show that the vast majority of patients requesting physician-assisted suicide (PAS) fear loss of autonomy; enjoyment, and personal dignity. [1] Many such patients fear becoming a burden to their families. These emotional problems deserve empathic counseling—not death in a bottle. Furthermore, research has shown that when physicians intervene and successfully address issues such as pain, depression, and other medical problems, as many as 46% of patients seeking assisted suicide will change their minds. [2]

I do not believe that psychiatrists or other physicians should collude with the machinery of assisted suicide. That said, the bills’ provisions regarding a mental health evaluation are woefully inadequate. The bill speaks soothingly of “counseling”, but all it calls for is a single determination that the patient is “…not suffering from a psychiatric or psychological disorder or depression causing impaired judgment” and is not subject to “coercion.” There is no requirement for a thorough, face-to-face, psychiatric evaluation to assess subtle cognitive distortions that may fall short of a full-blown disorder.

Indeed, research has shown that some cancer patients requesting assisted suicide have subtle cognitive distortions that are clouding their judgment. [3] In real counseling, these distortions could be addressed and remediated. Furthermore, many terminally ill patients who may not meet criteria for a full-blown psychiatric disorder are nevertheless impaired in their judgment by feelings of despair, anxiety, hopelessness, and demoralization. These emotional states often fluctuate over time, and may compromise genuine autonomy or “authentic voluntarism,” as Dr. Laura Weiss Roberts has explained. [4]

Such cognitive and emotional nuances are unlikely to be detected in a single assessment of a dying patient, and would require a very sophisticated and knowledgeable mental health professional, such as a forensic psychiatrist. The current bills require only a “licensed mental health professional,” which includes a broad range of professions, several of which, in my view, would not have the expertise to detect subtle cognitive and emotional factors that may compromise genuine autonomy.

As for detecting “coercion,” it should be obvious that once the patient leaves the evaluation milieu—returning home, for example—the bills provide no mechanism whatsoever for assessing coercive influences in the family setting, which may push the patient to ingest the lethal drugs. Nor do the bills provide any procedural “safety lock” that would prevent children or others in the family from finding and ingesting the lethal drugs. Finally, the bills contain no requirement that suicidal patients be treated for any diagnosed psychiatric or psychological disorder.

To conclude: the tenets of Hippocratic medicine erect a wall of separation between physicians and assisted suicide. As Dr. Leon Kass has put it, “We must care for the dying, not make them dead.” [5] Accordingly, I urge you to reject these bills and re-focus your attention on providing accessible, state-of-the-art palliative care to our patients with terminal illnesses.

Respectfully,

Ronald W. Pies, MD
Professor Emeritus of Psychiatry, Lecturer on Bioethics & Humanities;
SUNY Upstate Medical University;
Clinical Professor of Psychiatry,
Tufts University School of Medicine;
Editor-in-Chief Emeritus, Psychiatric Times
piesr@upstate.edu

References

1. The most common reasons for requesting medical aid in dying were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%). Loggers ET, Starks H, Shannon-Dudley M, Back AL, Appelbaum FR, Stewart FM. Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med. 2013;368(15):1417-1424. doi: 10.1056/NEJMsa1213398.

2. Linda Ganzini et al., “Physicians’ Experiences with the Oregon Death with Dignity Act,” 342 New Eng. J. Med. 557, 557 (2000).

3. For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, note 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. Levin TT, Applebaum AJ. Acute cancer cognitive therapy. Cogn Behav Pract. 2014;21(4):404-415.

4. Roberts LW. Informed consent and the capacity for voluntarism. Am J Psychiatry. 2002 May;159(5):705-12. doi: 10.1176/appi.ajp.159.5.705. PMID: 11986120.

5. Kass LR. Dehumanization triumphant. Conn Med. 1996;60(10):619-620

For further reading:

Ronald W. Pies, MD, Annette Hanson, MD

Twelve Myths About Physician Assisted Suicide and Medical Aid In Dying

July 7, 2018

https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide

Against Assisted Suicide

July 8, 2021

Ronald W. Pies, MD, Mark S. Komrad, MD, Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS, Annette Hanson, MD

https://www.psychiatrictimes.com/view/against-assisted-suicide

Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Ann Intern Med. 2017 Oct 17;167(8):576-578. doi: 10.7326/M17-0938. Epub 2017 Sep 19. PMID: 28975242.

Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS, Ronald W. Pies, MD. Two Misleading Myths Regarding “Medical Aid in Dying.” Psychiatric Times Vol 35, Issue 8, Volume 35, Issue 8. August 1, 2018.

Two Misleading Myths Regarding “Medical Aid in Dying” (psychiatrictimes.com)