Physician Assisted Suicide and the Autonomy Myth.

On October 27, Dr Ronald Pies and Dr Cynthia 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.

Dr Pies and Dr Geppert are both 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.

The following is a commentary by Psychiatrist Dr Mark Komrad:

This is one of the more important papers to 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 the person be reassessed prior to such delayed use.

Current statues, procedures, clinical training and time constraints all lead to a 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

Similar article: Assisted suicide and the myth of autonomy (Link to the article)