Response to: The Paradox of Assisted Suicide.

Mara Buchbinder's thesis: The Paradox of Medical Aid in Dying suggests that legalizing assisted suicide is popular because the practice is rare. Buchbinder also asserts that legalizing assisted suicide improves the death experience because patients can plan and discuss their death.

Dr's Pies, Geppert, Komrad and Hanson respond.

Dear Colleagues,

As psychiatrists and medical ethicists, we strongly disagree with anthropologist Mara Buchbinder, Ph.D.’s “Perspective” in the New England Journal of Medicine. [1] We believe Buchbinder’s thesis ignores the central, ethical issue underlying physician-assisted suicide (PAS) and offers several fallacious justifications for PAS.

First: nowhere in Buchbinder’s analysis is there any discussion of whether PAS is ethically justified, or consistent with the values of Hippocratic medicine. Many prominent medical organizations have repeatedly said it is not. [2,3,4]

Furthermore, it is a morbid irony to assert that an "unintended benefit" of MAID laws is to help "…start new conversations about what matters most to patients in the final stages of serious illness…” Does Buchbinder seriously believe that such intimate physician-patient conversations require legislation authorizing medically-assisted suicide on demand?

In truth, discussing MAID with a terminally ill patient narrows the conversation and orients the patient toward death as the preferred option. Responsible palliative care identifies options based on the patient’s actual goals and values [5]

Equally fallacious is Buchbinder’s reference to “this potential of MAID to control uncertainty” stemming from “the current historical moment.” The implication that a patient’s anxiety over “political unrest, economic instability, [and] climate change” is appropriately addressed by offering medically assisted suicide is stunning in its perversity.

As medical ethicist Dr. Leon Kass has observed, “We must care for the dying, not make them dead.” [6]

Respectfully,

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

References

1. Buchbinder M. The Paradox of Medical Aid in Dying. NEJM 395;5 July 30, 2026 [attached]

2. 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

3. American Medical Association Code of Ethics. https://code-medical-ethics.ama-assn.org/ethics-opinions/physician-assisted-suicide

4. WMA Declaration on Euthanasia and Physician-Assisted Suicide. (2019). https://www.wma.net/policies-post/declaration-on-euthanasia-and-physician-assisted-suicide/

5. Geppert CM. Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come. Am J Bioeth. 2015;15(7):34-43. doi: 10.1080/15265161.2015.1039720. PMID: 26147264.

6. Kass L. Dehumanization Triumphant. First Things. Aug. 1, 1996. https://firstthings.com/dehumanization-triumphant/

Proposed UK Assisted Dying Bill Fails Public Safety Test

This letter was published in the British Medical Journal.

Dear Editor,

As the UK Parliament prepares to debate assisted dying, its impact on those with mental health conditions, particularly eating disorders, must be urgently considered. If legalised, the proposed bill may enable patients with treatable eating disorders who have life-threatening malnutrition and/or feel suicidal to qualify for assisted death. Looi (1) highlights global expansion in assisted dying laws, yet gaps in safeguarding vulnerable groups remain.

Research suggests assisted dying laws have already led to preventable deaths of young people with eating disorders in multiple countries (2). At least 60 individuals with eating disorders have died through physician-assisted death, including in jurisdictions limiting the practice to terminal conditions. Of these, one-third involved women under 30. These deaths raise profound ethical concerns, as many patients were severely depressed or suicidal when deemed eligible.

These patients did not have concurrent terminal illnesses. Rather, clinicians asserted their eating disorders were “untreatable,” offering limited substantiating evidence. Some practitioners suggested patients had “terminal anorexia,” a term not recognised by any medical authority (3). Downs et al. (4) described it as a “nosological free-for-all,” highlighting the danger of inventing new illness classifications to justify ending vulnerable lives under the guise of medical treatment. Empirical efforts to validate terminal anorexia have raised significant questions about its validity (5). Anorexia nervosa is not a terminal condition; almost all the medical complications of eating disorders are reversible with nutrition and weight restoration (6).

The proposed bill aims to restrict eligibility to terminal illness — in practice, this safeguard is porous. In Oregon US, officials interpret “terminal illness” as any condition expected to cause death within six months if untreated (7). Patients with non-terminal conditions can become terminal by choosing to forego life-extending treatments, such as dialysis. This has led to deaths in patients with non-terminal conditions; including anorexia, arthritis, and hernias (8). The wording of the proposed U.K. bill similarly allows for this broad interpretation, offering minimal protection to vulnerable patients (9).

Assessing capacity to make a life-ending decision is particularly fraught in patients with malnutrition or mental distress (10, 11) who may appear lucid and articulate, yet struggle to process information fully. Evidence suggests that clinicians’ judgments of capacity in these patients are often inconsistent (11). In Oregon, only three individuals who received lethal prescriptions (1%) were referred for psychiatric evaluation in 2023, down from 33% in previous years (12), raising concerns that evaluators have become less cautious about capacity and psychiatric comorbidities.

Moreover, evidence from jurisdictions where assisted dying is legal reveals weak oversight and opaque reporting mechanisms (13). For example, U.S. oversight agencies confirmed anorexia nervosa has been documented as a terminal illness in cases of assisted death; however, these cases are hidden in public reports under the broad category “Other Illnesses” (2). Officials declined to disclose the exact number of cases, and agencies have limited authority to investigate potential misapplications of the law.

In the UK, the Court of Protection has already allowed treatment withdrawal and palliative care for eating disorders deemed ‘untreatable’ (14). However, researchers have raised concerns that many patients are labeled 'untreatable' without having received adequate treatment (4). If the proposed bill passes, “palliative care for eating disorders” may expand to assisted dying, undermining protections for those with complex, often stigmatised mental health conditions.

Evidence from other jurisdictions should serve as a stark warning to UK policymakers. The question before Parliament is not only whether individuals have the right to die, but whether assisted dying can be safely implemented within the NHS. Evidence from other countries shows that safeguards intended to protect vulnerable patients from medically-assisted suicide have failed. We urge MPs to weigh these findings carefully and vote against the bill—it fails the public safety test.

Chelsea Roff
Executive Director, Eat Breathe Thrive

James Downs
Peer Researcher and Expert by Experience

Agnes Ayton
Consultant Psychiatrist in Eating Disorders
Oxford Health NHS Foundation Trust

Ashish Kumar
Chair, Faculty of Eating Disorders, RCPsych
Clinical Director at Mersey Care Foundation Trust

Angela Guarda
Professor of Psychiatry and Behavioral Sciences Director
Eating Disorders Program Johns Hopkins School of Medicine

Patricia Westmoreland
Medical Director, ACUTE Center for Eating Disorders & Severe Malnutrition Department of Psychiatry, University of Colorado

Philip Mehler
Founder, ACUTE Center for Eating Disorders & Severe Malnutrition
Professor of Medicine, University of Colorado

Mark S. Komrad
Faculty of Psychiatry
Johns Hopkins School of Medicine, Tulane, and University of Maryland

Paul Appelbaum
Dollard Professor of Psychiatry, Medicine & Law
Columbia University

Ronald W. Pies
Professor Emeritus of Psychiatry
SUNY Upstate Medical University

Annette Hanson
Assistant Professor
University of Maryland

Catherine Cook-Cotton
Licensed Psychologist, Professor and Researcher
University at Buffalo (SUNY)

Anita Federici
Clinical Psychologist
Center for Psychology and Emotion Regulation

Hope Virgo
Founder of #DumptheScales, Author,
Mental Health Campaigner

Ali Ibrahim
Consultant Psychiatrist, Eating Disorders

Suzanne Baker
Family & Carer Representative, FEAST UK

Marissa Adams
Peer Research & Expert by Experience

References
1. Looi, M. K. (2024). Assisted dying laws around the world. bmj, 387.
2. Roff, C., & Cook-Cottone, C. (2024). Assisted death in eating disorders: a systematic review of cases and clinical rationales. Frontiers in Psychiatry, 15, 1431771.
3. Gaudiani, J. L., Bogetz, A., & Yager, J. (2022). Terminal anorexia nervosa: three cases and proposed clinical characteristics. Journal of eating disorders, 10(1), 23.
4. Downs, J., Ayton, A., Collins, L., Baker, S., Missen, H., & Ibrahim, A. (2023). Untreatable or unable to treat? Creating more effective and accessible treatment for long-standing and severe eating disorders. The Lancet Psychiatry, 10(2), 146-154.
5. Robison M, Udupa NS, Abber SR, Duffy A, Riddle M, Manwaring J, Rienecke RD, Westmoreland P, Blalock DV, Le Grange D, Mehler PS, Joiner TE. "Terminal anorexia nervosa" may not be terminal: An empirical evaluation. J Psychopathol Clin Sci. 2024 Apr;133(3):285-296. doi: 10.1037/abn0000912. PMID: 38619462; PMCID: PMC11062513.
6. Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med. 2016 Jan;129(1):30-7. doi: 10.1016/j.amjmed.2015.06.031. Epub 2015 Jul 10. PMID: 26169883.
7. Stahle F. Notarized Questions to Oregon Health Authority. January 2018. Available online: https://drive.google.com/file/d/1XopTDjBA2SAVBGBxpDazNN899eTHixSe/view
8. Oregon Health Authority. Oregon Death with Dignity Act: 2021 Data Summary (2022). Available online at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARC...
9. Leadbeater K. Terminally Ill Adults (End of Life) Bill. Nov 11, 2024. https://bills.parliament.uk/bills/3774 [Accessed 14th November 2024].
10. Van Elburg, A., Danner, U. N., Sternheim, L. C., Lammers, M., & Elzakkers, I. (2021). Mental capacity, decision-making and emotion dysregulation in severe enduring anorexia nervosa. Frontiers in Psychiatry, 12, 545317.
11. Elzakkers, I. F. F. M., Danner, U. N., Grisso, T., Hoek, H. W., & van Elburg, A. A. (2018). Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice. International journal of law and psychiatry, 58, 27–35. https://doi.org/10.1016/j.ijlp.2018.02.001
12. Oregon Health Authority. Oregon Death with Dignity Act: 2023 Data Summary (2024). Available online at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARC...
13. Raikin, A. (2024). A pattern of non-compliance. The New Atlantis. 11 November 2024.
14. Cave, E., & Tan, J. (2017). Severe and enduring anorexia nervosa in the England and Wales Court of Protection. International Journal of Mental Health and Capacity Law, 23(17).

No safe way to legalise euthanasia

Kevin Yuill, emeritus professor of history at the University of Sunderland and CEO of Humanists Against Assisted Suicide and Euthanasia (HAASE), wrote an article, published in Spiked on June 18, 2024.

by Kevin Yuill

For the first time in history, both main candidates in a UK General Election are openly in favour of legalising assisted suicide or euthanasia (ASE). Whether Labour or the Conservatives win in July, the Suicide Act 1961 will likely be called into review.

Last week, prime minister Rishi Sunak was asked by reporters at the G7 summit in Italy if he would vote for a change in the law on ‘assisted dying’. He replied: ‘I’m not opposed to it, in principle, and it’s a question of making sure the safeguards are in place and are effective.’

This may be a moot point, given that Sunak is trailing Labour leader Keir Starmer by 20 points in the polls. Besides, Sunak’s position was carefully couched. Rather than giving his full-throated support, he said he is ‘not opposed’. But that didn’t stop Sarah Wootton, chief executive of Dignity in Dying, from being able to say that, whoever gets in, ‘neither are opposed to reform’ of the UK’s current ban on ASE.

Perhaps the one thing we know about the infamously slippery Starmer is that he has a track record of supporting ASE. In March this year, he said was personally in favour of legalisation and he promised that MPs would get a free vote on it in the next parliament. Still, even he said that any change in the law must be accompanied by ‘safeguards with teeth to protect the vulnerable’ from abuse. These imagined safeguards are certainly doing a lot of heavy lifting. But could they actually work?

Looking at the evidence, it is difficult to avoid the conclusion that the only ‘safeguard’ that really works or lasts is the present law, which prevents ASE entirely. In every country where ASE is legal, the safeguards have fallen rapidly and initially low numbers of assisted deaths have surged.

Just look at the example of Australia, where ASE is largely legalised. Since legislation was passed in 2017, we have heard a constant clamour for more ‘improvements’ in the law, as pro-euthanasia organisation Go Gentle Australia disingenuously phrases it. What this really means is expansions of the current eligibility criteria. Last week, Australian publication the Age complained that, in the state of Victoria, many of the 68 safeguards that had reassured Victorians that ASE would be safe ‘are now obsolete and severely limit access’. The Age insisted that doctors should be allowed to initiate conversations about euthanasia and called for the removal of other ‘unnecessary hurdles’ to ASE. It is not difficult to see how this could lead to vulnerable people being pressured into accepting an assisted death.

Even in the US state of Oregon – which proponents of ASE like to hold up as evidence that safeguards work – the minimum period between a request for an assisted suicide and a patient’s death was reduced from 14 days to 48 hours in 2021.

Everywhere that ASE has been legalised, the eligibility criteria has ended up expanding. As psychiatrists Mark Komrad and Annette Hanson note in the Psychiatric Times this month, ASE legislation begins ‘with the “low-hanging fruit” of end-stage or terminal illness and gradually broadens’ to encompass other non-physical illnesses or conditions.

In Colorado, there have been cases where people have been helped to die because of anorexia. Dutch law similarly allows ASE for a variety of non-physical ailments, extending even to allow the killing last month of a physically healthy 29-year-old who suffered from severe depression. In the Netherlands in 2010, there were two cases of ASE involving psychiatric suffering. In 2023, there were 138, making up 1.5 per cent of the 9,068 euthanasia deaths.

In Canada, ASE was legalised in 2016 under the medical assistance in dying (MAID) programme. This was initially only intended for people whose deaths were ‘reasonably foreseeable’. But a court decision forced the government to expand its criteria effectively to all those with a permanent disability.

Safeguards simply do not work, even when they supposedly have ‘teeth’. When legalised, ASE rapidly turns death into a form of treatment for anyone deemed to be living an ‘inconvenient’ life – from the mentally unwell to the physically disabled.

The only good news is that, after 4 July, there will be a debate both in and outside of parliament. We should use this opportunity to counter the emotional appeals of our political class with the tragic realities of places where ASE is legal. Legalising assisted suicide is not so much a slippery slope as a moral precipice.

A critique: The Widening Scope of Assisted Suicide in the US

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Psychiatrists, Dr's Mark Komrad, Annette Hanson, Cynthia Geppert and Ronald Pies wrote an excellent article on - The Widening Scope of Assisted Suicide in the US that was published by the Psychiatric Times on June 6, 2024. Komrad et al., have been researching assisted suicide in the US for several years. Komrad et al write:

Physician-assisted suicide (PAS)—commonly but misleadingly called “medical aid in dying” (1) —is now legal in 11 jurisdictions in the US. PAS remains an area of great controversy among physicians, medical ethicists, and various patient advocacy groups, as evidenced by numerous opinion pieces in Psychiatric Times. (2,3) While we recognize that individuals of good conscience may differ on the ethics of PAS, we have consistently maintained—as the American Medical Association has opined—that (4):

“Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”

This position has also been consistently taken by the World Medical Association. (5) Despite such clear statements, we and others have called attention to the ever-expanding eligibility criteria for PAS/euthanasia (PAS/E), particularly in Canada, Belgium, and the Netherlands. In essence, every one of these foreign jurisdictions that has legalized PAS/E has eventually expanded them—a phenomenon often referred to as “the slippery slope.” (6)

Komrad et al explain that assisted suicide laws are legalized based on restrictions related to terminal illness and then it expands.

The expansion typically begins with the “low-hanging fruit” of end-stage or terminal illness and gradually broadens to “chronic, nonterminal, or treatment-refractory illness,” as one of us (M.S.K.) has shown. (7)

Whenever a line is drawn to limit eligibility criteria, those just outside the line protest, based on understandable (if misplaced) ethical principles of justice, fairness, and parity. Consequently, the boundaries of eligibility for PAS/E have been greatly stretched—in practice, in law, and in guidelines issued by professional organizations. (8)

Komrad et al, then explain how the slippery slope exists in the US.

As opponents of PAS/E, we often hear proponents claim that the slippery slope argument is merely hypothetical—an alarmist bogeyman used to scare away supporters of PAS/E.9 We also hear that, even if the slippery slope metaphor applies in foreign countries, “it would never happen here” in the US. We respectfully disagree. Although the angle of the slope is considerably greater in Canada and the Benelux countries (Belgium, the Netherlands, and Luxembourg) than in the US, we find troubling signs of slippage here at home.

In this piece, we critically examine 2 such examples: (1) the introduction of California Senate Bill 1196, along with expanded PAS criteria in several other states; and (2) 3 cases of PAS in Colorado, in which patients with anorexia nervosa died from lethal prescribed drugs.

Komrad et al then comment on California Senate Bill 1196: A Harbinger of Things to Come?

California Senate Bill 1196, the End of Life Option Act, was introduced by Senator Catherine Blakespear and represented a radical departure from existing California law.10 SB 1196 proposed several changes (Table).11 Additionally, it contained language that would have turned these practices into a quasi-research protocol by requiring the prescribing physician to report the type of lethal medications prescribed, the time from drug ingestion/administration to death, and any observed complications.

This radical bill was “a bridge too far” even for some groups that have long supported PAS. For example, the group Compassion & Choices stated, “Compassion & Choices and the Compassion & Choices Action Network respectfully oppose SB1196…” which the group viewed as posing “…significant risks to the current medical aid-in-dying law, potentially undermining its purpose and availability.”12

Ultimately—and fortunately—Blakespear withdrew this extreme proposal, and California dodged the proverbial bullet. However, in our view, the mere fact that SB 1196 was proposed is cause for great concern and a sign of the slippage we have witnessed in other countries.

Komrad et al conclude this section by stating that SB 1196 was offering a much wider expansion of the assisted suicide law than other proposed expansions. They then comment on the expansion of the definition of terminal that permitted at least three Colorado assisted suicide deaths for Anorexia Nervosa. They write:

In March of 2022, the Colorado Sun ran the following headline: “Denver doctor helped patients with severe anorexia obtain aid-in-dying medication, spurring national ethics debate.”(17)

The backstory, as told in the Colorado Sun article, was this(17):

“Dr Jennifer Gaudiani, an internal medicine doctor who specializes in eating disorders, published a paper in which she describes the deaths of [3] patients with anorexia nervosa [AN]. One 36-year-old woman died after ingesting the lethal doses prescribed by another doctor, with Gaudiani serving as consulting physician. Another 36-year-old woman died of severe malnutrition on the same day she planned to take aid-in-dying medication prescribed by Gaudiani.”

The third patient—Alyssa B—was actually a coauthor of the paper with Gaudiani. According to the published paper, “Dr G prescribed the [medical aid in dying] medications about 6 weeks after Alyssa entered hospice care.”18The Gaudiani et al paper is notable in acknowledging that:

“Alyssa had not completed a full residential eating disorder program; never fully restored weight; never tried newer psychedelic options such as ketamine, psilocybin, or MDMA; and hadn’t had a feeding tube. Dr G acknowledged that all but the feeding tube might ordinarily be undertaken prior to someone’s seeking end-of-life care for AN. Yet, [Alyssa] had been suffering for so long, and despite many conversations about all these treatment possibilities, Alyssa would not consent to any of them. Therefore, given her clarity of understanding around these issues and her sense that she could not fight anymore, everyone had to accept that they weren’t meaningful options.”

Komrad et al explain why assisted suicide for anorexia was so wrong.

Not surprisingly, the published paper and its rationale were vociferously criticized by many in the psychiatric community. For example, Angela Guarda, MD—the director of the eating disorders program at Johns Hopkins Hospital in Baltimore, Maryland—is quoted as saying that using aid-in-dying medication for anorexia patients is “alarming” and “fraught with problems.” This is partly because “…it is impossible to disentangle this request [for PAS] from the effects of the disorder on reasoning, and especially so in the chronically ill, demoralized patient who is likely to feel a failure.”(17)

We strongly agree with Guarda and regard the 3 cases as exemplifying the slippery slope of eligibility for PAS/E in the US. One of us [C.M.A.G.] has argued that the concept of futility in the treatment of anorexia nervosa is not supported by current evidence and should not serve as the basis for decision-making in this condition. (19),(20)

Komrad et al conclude that California Bill SB 1196 and the cases of assisted suicide for anorexia are proof that a slippery slope exists with assisted suicide in America. They write:

In our view, the phenomenon of the slippery slope is, in large part, the expectable consequence of “normalizing” or naturalizing the physician’s direct or indirect killing of the patient via euthanasia or PAS, respectively. The more widely these acts are performed, the easier it becomes to mischaracterize them as forms of “medical care.” This is epitomized in the obfuscating euphemism medical aid in dying. As the American College of Physicians has stated (21):

“Terms for physician-assisted suicide, such as aid in dying, medical aid in dying, physician-assisted death, and hastened death, lump categories of action together, obscuring the ethics of what is at stake and making meaningful debate difficult.”

In truth, assisted suicide does not aid the dying process—it terminates dying by terminating the patient.

By the same token, the more PAS/E are viewed as medical care, the easier it becomes to broaden the eligibility criteria to encompass almost anyone who feels they are “suffering.” Then the slide down the slope can accelerate, from terminal conditions to chronic conditions (such as mental illness), as is happening in our culturally and geographically adjacent neighbor, Canada. That opens the path for the next drift in the evolving ethos—transforming one’s opportunity to seek these lethal procedures into the virtue of relieving loved ones from the burden of their condition.

Finally, we believe it essential that the American Psychiatric Association (APA) maintain its ethical opposition to PAS/E, consistent with the American Medical Association (AMA) Code of Ethics. (4) Doing otherwise will create a schism between the APA and the AMA. Indeed, we hope that as our colleagues consider these issues, they bear in mind the teaching from medical ethicist Leon Kass, MD: “We must care for the dying, not make them dead.” (22)

Link to the original article for references (Original article link).

Dr Komrad is a psychiatrist on the teaching staff of Johns Hopkins Hospital in Baltimore, Maryland. He is also a clinical assistant professor of psychiatry at the University of Maryland in Baltimore and on the teaching faculty of psychiatry at Tulane University in New Orleans, Louisiana.
Dr Hanson is director of the forensic psychiatry fellowship at the University of Maryland in Baltimore.
Dr Geppert is a professor in the Departments of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is the lead ethicist for the Western region and director of education at the Veterans Health Administration National Center for Ethics in Health Care in Washington, DC, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College in New York. She serves as the ethics editor for Psychiatric Times.
Dr Ronald Pies is a professor emeritus of psychiatry and a lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse, New York; a clinical professor of psychiatry emeritus at Tufts University School of Medicine in Boston, Massachusetts; and editor in chief emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.

Did California Dodge a “Right-to-Die” Bullet?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Mark Komrad

Psychiatrists, Dr's Mark Komrad and Annette Hanson, Ronald Pies and Cynthia Gepert, wrote a commentary on the recent attempted expansion of California's assisted suicide law that was published by the Psychiatric Times.

Komrad et al, express their concerns that, even though SB 1196 was pulled by its sponsor that it represents the strongest example of slippage with the US assisted suicide laws to a far more permissive position. They state:

As opponents of PAS/E, we often hear proponents claim that the “slippery slope” argument is merely hypothetical—an alarmist bogeyman used to scare away supporters of PAS/E. We also hear that, even if the slippery slope metaphor applies in foreign countries, “It would never happen here” in the US. We respectfully disagree. For while the angle of the slope is considerably greater in Canada and the Benelux countries than in the US, we find troubling signs of slippage here at home.

Annette Hanson

Komrad et al ask if SB 1196 is: A Harbinger of Things to Come? They explain:

California Senate Bill 1196 was introduced by Senator Catherine Blakespeare and represented a radical departure from existing California law.

Among its other provisions, SB 1196 proposed the following changes:

• It eliminated the California residency requirement for PAS.
• It replaced the criterion of “terminal disease” with “grievous and irremediable medical condition” that is “causing the individual to endure physical or psychological suffering… that is intolerable to the individual and cannot be relieved in a manner the individual deems acceptable.”
• It changed the criterion of the disease from “expected to result in death within 6 months” to “it is reasonably foreseeable that the condition will become the individual’s natural cause of death.” (This is identical to the vague language invented in Canada’s 2016 C-14 bill, which was never statutorily defined).
• It included a diagnosis of early to mid-stage dementia in the definition of a “grievous and irremediable medical condition.”
• It expanded the definition of “mental health specialist” to include neurologists and omitted any requirement for an evaluation by a psychiatrist or psychologist.
• It authorized “the self-administration of an aid-in-dying drug through intravenous injection.” This would have allowed health care practitioners to facilitate death by inserting an IV line—not merely writing a prescription, or dispensing and preparing the lethal drugs.

Ronald Pies

Additionally, SB 1196 contained language that would have turned these practices into a quasi-research protocol by requiring the prescribing physician to report the type of lethal medications prescribed; the time from drug ingestion/administration to death; and any observed complications.

Komrad et al explain how assisted suicide laws are "stretching the boundaries." They explain: 

This extraordinary attempt to expand California's law illustrates what many states may expect if laws permitting PAS (or euthanasia) are adopted. Indeed, contrary to the “It can’t happen here” argument, we have already seen examples of slippage in several US states. These expansionary rules may be categorized as modifications of (1) waiting periods for PAS; (2) conditions of PAS eligibility; or (3) expansion of authority to carry out PAS; or some combination of these modifications.

For example,

• In New Mexico, advanced practice nurses and physician assistants are now allowed to carry out assisted suicide, and the waiting period between evaluation and lethal prescription has shrunk from 15 days to 48 hours. In addition, “a provider can waive the 48-hour waiting period if the patient is unlikely to survive the waiting period.”
• In Oregon, the state residency requirement has been eliminated, and if the patient’s death is predicted to be within 15 days, the lethal drugs may be prescribed on the same day as evaluation of the patient. Notably, “Prescriptions for lethal doses of medication in Oregon increased by nearly 30% in 2023, the same year an amendment to the state's Death with Dignity Act removed the in-state residency requirement for patients…”
• In 2022, Vermont bill S.74 was signed into law, allowing patients to request the lethal prescription using telemedicine. S.74 also got rid of the final 48-hour waiting period. Then, in 2023, Vermont removed the residency requirement from Act 39, the Patient Choice at End of Life law.
• In Washington State, as of 2023, physician assistants and advanced registered nurse practitioners are now permitted to prescribe the lethal drugs, and mental competency can be evaluated by any licensed ‘mental health counselor.’ If death is deemed “imminent,” the lethal prescription can be written the same day as the eligibility evaluation.

Cynthia Geppert

As expansive as these recent modifications are, they pale in comparison to the radical changes proposed in SB 1196.

Komrad et al comment on the extension of assisted suicide to people with Anorexia Nervosa. They write:

In March of 2022, the Colorado Sun ran the following headline: “Denver doctor helped patients with severe anorexia obtain aid-in-dying medication, spurring national ethics debate.”

The article explains that Dr Jennifer Gaudiani assisted the suicides of three people with eating disorders. Komrad and Hanson explain:

The third patient—Alyssa B—was actually a coauthor of the paper with Dr Gaudiani. According to the published paper,18 “Dr. G prescribed the MAID medications about 6 weeks after Alyssa entered hospice care.”

The Gaudiani et al paper is notable in acknowledging that: 

“Alyssa had not completed a full residential eating disorder program; never fully restored weight; never tried newer psychedelic options such as ketamine, psilocybin, or MDMA; and hadn’t had a feeding tube. Dr. G acknowledged that all but the feeding tube might ordinarily be undertaken prior to someone’s seeking end of life care for AN. Yet, [Alyssa] had been suffering for so long, and despite many conversations about all these treatment possibilities, Alyssa would not consent to any of them. Therefore, given her clarity of understanding around these issues and her sense that she could not fight anymore, everyone had to accept that they weren’t meaningful options.”

Not surprisingly, the published paper and its rationale were vociferously criticized by many in the psychiatric community. For example, Dr Angela Guarda—the director of the eating disorders program at Johns Hopkins—is quoted as saying that using aid-in-dying medication for anorexia patients is “alarming” and “fraught with problems.” This is partly because “…it is impossible to disentangle this request [for PAS] from the effects of the disorder on reasoning, and especially so in the chronically ill, demoralized patient who is likely to feel a failure.”

Komrad et al explain how the three assisted suicide deaths of people with eating disorders is another clear sign of a practical slippery slope with US assisted suicide laws. 

They conclude their article by stating:

In our view, the phenomenon of the slippery slope is, in large part, the expectable consequence of “normalizing” or naturalizing the physician’s direct or indirect killing of the patient; ie, via euthanasia or PAS, respectively. The more widely these acts are performed, the easier it becomes to mischaracterize them as forms of “medical care.” This is epitomized in the obfuscating euphemism, “medical aid in dying.” As the American College of Physicians has stated:

“Terms for physician-assisted suicide, such as aid in dying, medical aid in dying, physician-assisted death, and hastened death, lump categories of action together, obscuring the ethics of what is at stake and making meaningful debate difficult.”

In truth, assisted suicide does not “aid” the dying process—it terminates dying by terminating the patient.

By the same token, the more PAS and euthanasia are viewed as medical care, the easier it becomes to enlarge the eligibility criteria to encompass almost anyone who feels they are “suffering.” Then the slide down the slope can accelerate, from terminal conditions to chronic conditions (such as mental illness), as is happening in our culturally and geographically adjacent neighbor, Canada. That opens the path for the next drift in the evolving ethos—transforming one’s “opportunity” to seek these lethal procedures into the virtue of relieving loved ones from the burden of their condition.

Finally, we believe it essential that the APA maintain its ethical opposition to PAS/E, consistent with the American Medical Association Code of Ethics.4 Doing otherwise will create a schism between the APA and the AMA. Indeed, we hope that as our colleagues consider these issues at the APA meeting, they bear in mind the teaching from medical ethicist Dr Leon Kass: “We must care for the dying, not make them dead.”

It is my belief that SB 1196 is the direction of the assisted suicide lobby, not just an experimental bill to gage a reaction. 

Psychiatrist: Anorexia does not justify Aid in Dying

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Psychiatrists Dr Patricia Westmoreland, Dr Cynthia Geppert, Dr Mark Komrad, Dr Annette Hanson, Dr Ronald Pies and Dr Philip Mehler wrote a response to the story of Lisa Pauli, a Canadian who lives with Anorexia Nervosa (AN) who wants to die by euthanasia (MAiD) that was published in the Psychiatric Times on October 11, 2023. (Link to the article).

The article that is based on clinical research counters the concept that AN is a condition that can lead to approval for euthanasia or assisted suicide. The authors write:

In a recent article published by Reuters, a 47-year-old Canadian woman with anorexia nervosa (AN) tells a reporter that when an expansion of the criteria for medically assisted death comes into effect in March 2024, she plans to apply for medical aid in dying (MAID). Lisa Pauli, who has suffered from AN for many decades, stated that she goes days without eating solid food. She characterized every day as “hell,” and noted, “I’m so tired. I’m done. I’ve tried everything. I feel like I’ve lived my life.” However, it is worth noting that 3 issues received scant attention in the article: the types of treatment she had tried, the extent to which any comorbid psychiatric conditions (such as depression) had been treated, and whether she even has mental capacity to make this decision.

Proponents of MAID, otherwise known as physician-assisted suicide (PAS)—the term preferred by the American College of Physicians and used in the American Medical Association Code of Ethics—cite “terminal anorexia” as a new, valid construct justifying MAID for individuals with severe, longstanding AN. Terminal anorexia has been recently applied to individuals who:

(a) have a diagnosis of AN and are age 30 or older;

(b) have had prior, persistent engagement in high quality, multidisciplinary eating disorder treatment;

(c) express a clear, consistent wish to stop trying to prolong their lives;

(d) possess adequate decision-making capacity;

(e) understand that further treatment of AN will be futile; and

(f) accept that death will be the natural outcome of discontinuing treatment.

But is terminal anorexia a valid construct? Several eating disorder experts, with decades of experience in the field, have opined that this term cannot adequately be defined and should therefore not be used.

Regarding criterion (a)—that, to be considered terminal, an individual must be 30-years-old or older—Mack et al noted that it is a commonly held myth that older individuals cannot recover from AN. Both Mack et al and Guarda et al cited the longitudinal study by Eddy et al, indicating that, while individuals with AN may not recover in the first 5 to 10 years of their illness, two-thirds of individuals with AN had recovered after 22 years.

Interestingly, the mean age of participants in the Eddy et al study was 47—the same age as Lisa Pauli. It is thus concerning that Ms Pauli’s recovery would be deemed impossible. While the term terminal is certainly well-established in certain medical spheres of health care, those conditions entail clear, objective parameters establishing that an end-stage illness is untreatable and that death is naturally imminent, even in the face of continued treatment for the underlying illness. Examples include certain cancers; end-stage cirrhosis; heart failure; or multiple organ failure (MOF) from sepsis. Such objective parameters have no parallel in AN.

The second criterion (b) is “prior persistent engagement in high quality multidisciplinary eating disorder treatment.” Individuals in the case report in which Gaudiani used the term, terminal anorexia do not appear to have had such treatment; eg, 2 brief inpatient stays before leaving against medical advice; failure to complete residential treatment; and lack of full weight restoration. This may also be the case with Pauli, who apparently was hospitalized on only 2 occasions for her longstanding eating disorder. There are 2 additional factors which make the inclusion of the “prior persistent treatment” criterion concerning. First, individuals with eating disorders are frequently ambivalent regarding treatment, and often completely opposed to it, given the necessary but distressing emphasis on weight restoration. Second, there is commonly a lack of access to high quality multidisciplinary treatment. Sharpe et al pointed out that Gaudiani et al presupposed that high quality treatment exists and is accessible to all individuals with AN. This, according to Sharpe et al, is “discordant with our experiences as patients, clinicians and peer advocates within systems of ED treatment.”

Both fiscal and societal pressures may also not favor costly treatment for a chronic mental health condition. In Canada, it may take 4 months to enroll in any mental health treatment and as much as 417 days to receive specialized eating disorder treatment. The more expeditious option of MAID (90 days for patients whose death is not imminent, and immediate approval for those whose death is termed imminent) may appeal to those who have become hopeless. Even more concerning is the potential appeal of MAID to contain cost and deal with waitlists for mental health care. A glaring example of this was a patient who presented to an emergency department in Vancouver with suicidal ideation. Her goal that day was simply to keep herself safe and be admitted to the hospital. However, given the long wait time to see a psychiatrist, the evaluating clinician asked if she had considered MAID for her psychiatric illness. She was told of another patient who had reportedly found “relief in death.” The hospital subsequently apologized to the patient.

Similarly, in response to the proposed definition of terminal anorexia, Elwyn—an individual with lived experience of severe and enduring AN—reflected on how receiving a terminal diagnosis would substantially increase an individual’s sense of burdensomeness; decrease their sense of meaningfulness; and (along with decreasing any hope of recovery) decrease attempts at seeking help. All of these factors, in addition to commonly co-occurring depression and anxiety, may actually increase risk for suicide, whether medically assisted or via other methods.

Regarding criteria (c) through (f)—ie, the person expresses a clear, consistent wish to stop trying to prolong their life; has adequate decision-making capacity; understands that further treatment will be futile; and accepts that death will be the natural outcome of discontinuing treatment—several caveats are in order. First, individuals with severe eating disorders frequently lack decisional capacity. To be sure: there is a difference between a decision that seems illogical versus one arising from lack of capacity. But while AN is not synonymous with decisional incapacity, it is nonetheless troubling that a decision with an irreversible outcome is being made by an individual with questionable decision-making capacity, particularly in cases of severe AN.

The delusional level of cognitive distortions regarding food and body image is the irrational lens through which the decision to refuse treatment and to seek MAID is filtered. Accordingly, the clinician who assumes that the patient has the capacity to consent to assisted suicide (rather than seeking further treatment) is not relieving the patient’s suffering, but is actually furthering and colluding with the disease itself. This is especially true when individuals with AN are highly ambivalent about recovery.

Furthermore, that MAID appears to be not just offered but encouraged exploits the ambivalence that is intrinsic to AN. As noted by Geppert, given that decisional capacity is almost always regained with weight restoration, are we not then obligated to treat an individual so that they are able to regain capacity? In severe AN, involuntary treatment provided by a behavioral inpatient specialty program can be lifesaving—and when effective, is often met with gratitude by patients.

Back to Lisa Pauli. Although we have not personally examined Ms Pauli, the fact that she reports minimal prior treatment for her eating disorder; that recovery is not impossible at age; that there is no mention of strategies to treat comorbid mental illness; and that, being undernourished, she may well lack capacity, all argue against her illness being terminal and MAID being her only option.

Instead, efforts should be directed toward improving access to care in the United States and Canada for individuals with eating disorders, rather than providing “a form of state-assisted suicide,” as a Canadian psychiatrist described it. Even if a curative approach were not possible in Ms Pauli’s case, both harm reduction and palliative care are options for managing AN and its comorbidities. These interventions could lead to enhanced quality of life, even if that life proved to be shorter than anticipated; and would also give individuals like Ms Pauli the option of exploring a curative approach in the future.

The notion of providing MAID for an individual in whom a so-called terminal illness cannot be accurately defined, is both troubling and unjustifiable. As psychiatrists in the United States, we owe it to our patients to join with legislators who fight for equitable access to mental health care. Psychiatrists must strive to provide high-quality, evidence-based care, and to hold out hope for our patients until they can do so themselves. When further treatment after judicious deliberation and consultation appears unproductive or unwarranted, let us provide comfort and support—not take steps to provide the suicide some patients seek.

Article references are contained within the original article. (Link to the article)

More articles on this topic:

• Canadian woman with anorexia wants to die by euthanasia (Link). 
• Assisted suicide for anorexia: Anorexia is not a death sentence. I am living proof of this (Link).
• Assisted suicide for Anorexia Nervosa (Link).
• Assisted suicide for Anorexia Nervosa is Abandonment (Link). 
• Assisted suicide for Anorexia Nervosa expands assisted suicide from terminal to chronic conditions (Link).
• Assisted suicide lobby admits that assisted suicide for Anorexia Nervosa violates the law (Link).

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).
  

Dr. Anne Hanson's Testimony Opposing Assisted Suicide

Suicide Contagion; Safeguard Failures; and Implications for the Practice of Psychiatry 

This article was published by Choice is an Illusion.

Anne Hanson MD

The Maryland Psychiatric Society opposes HB 643, the End-of-Life Option Act. Since this bill was first introduced in 2015, the Maryland Psychiatric Society has extensively deliberated the legislation within the organization through several listserv discussions, a member survey, and a four hour pro-con debate sponsored jointly with the Maryland somatic physician's organization, Med Chi. In addition to reviewing the legislation each year, we considered information contained in the American Psychiatric Association's resource document on assisted suicide (APA 2017) and other literature as cited in the references below.

The Maryland Psychiatric Society recognizes that this is a divisive issue and that some of our members disagree with the organization's position. Those members have been encouraged to contact their elected officials to contribute their thoughts and we welcome consideration of both sides of this serious policy.

The Maryland Psychiatric Society maintains its opposition to HB 643. There are three general areas of concern.

1. Suicide Contagion

Promotion of this bill, and assisted suicide laws generally, transmit a dangerous message to vulnerable Maryland citizens. According to the Centers for Disease Control,  at any given point in time 4% of people are experiencing suicidal thoughts. One-sixth of those individuals will attempt suicide (1.4 million Americans), and 3% will die (Shreiber and Culpepper 2020). Translated into Maryland numbers, this means that 242,000 people are presently thinking of killing themselves, 40,333 will attempt suicide, and 1210 will die.

Suicide clusters and contagion are well established phenomena with documented connections to media coverage and publicity (Blasco-Fontecilla 2013). The Centers for Disease Control and the World Health Organization both promulgate guidelines for the media coverage of high profiles suicides (Carmichael 2019). These guidelines advise against the portrayal of self-destruction as a “brave,” or “romantic,” and discourage reports which idealize suicidal behavior. They also caution against explicit discussion of suicide methods. These recommendations were developed in part due to a study which demonstrated that deaths by helium asphyxiation increased by more than 400% in New York following publication of the book Final Exit in 1991 (Marzuk 1993).

Proponents of assisted suicide laws violate these public health recommendations when they describe self-destruction as a “graceful” or “beautiful” expression of personal autonomy (Death With Dignity 2020). To date there have been no well designed studies to clarify the relationship, if any, between adoption of assisted suicide laws and states rates of un-assisted suicide. However, following the highly publicized death of Brittany Maynard in 2014 the number of assisted deaths by lethal medication in Oregon nearly doubled, from 71 in 2013 to 132 in 2015 (Oregon 2015). In a letter to the Colorado Springs Gazette, Dr. Will Johnston documented the case of a young man who was inspired to research suicide methods online after being impressed by, and admiring, Brittany Maynard's suicide video (Johnston 2016).

Here in Maryland, two people with serious mental illness have sought psychiatric help to die on the basis of their mental illness. One was a resident of the Maryland state hospital system and made a request for lethal medication on the day the 2019 bill failed in the Senate (Hanson, personal communication). Another was a resident of the Eastern Shore with schizophrenia who contacted several forensic psychiatrists for a capacity assessment in order to apply for euthanasia in Switzerland (Neghi and Crowley, personal communications).

Adoption of this law carries serious implications for people with mental disorders who would demand equality under the law. People with serious and treatment-resistant eating disorders could qualify, since qualification is based upon prognosis rather than diagnosis.

2. Safeguard Failures

The Maryland Psychiatric Society considers the statutory safeguards to be inadequate. Furthermore, they historically have been ignored without consequences to the negligent physicians.

Between 1998 and 2012 a total of 22 Oregon physicians were referred to the Board of Medical Examiners for non-compliance with the provisions of the Death With Dignity Act. None could be sanctioned due to the “good faith” protections of the law, even when required witness attestations were missing. No attempt has been made by Oregon, or any independent researchers, to document unreported cases in Oregon since the entry into force of the DWDA. The true reporting rate in Oregon is therefore unknown (Lewis 2013).

Similarly, in the first year of the Colorado law all prescribing physicians attested that they followed the law even when 42 cases were missing the consultant's evaluation, 22 had no written request, and nine of 69 cases were not reported at all by the physician (Colorado 2017).

In 2016 the Des Moines Register investigated ten years of data in Washington and Oregon, and found that in 40% of cases the reports were missing key data.

Failure to submit required reports, or to hold physicians accountable for reporting failure, is a substantial weakness of this legislation. Even if all required documents were accounted for, there has been no study to date to confirm the accuracy and specificity of these statutory safeguards.

In Maryland, one physician was even willing to violate our state's criminal prohibition. The late Dr. Lawrence Egbert admitted participation in the assisted suicide deaths, by helium asphyxiation, of six non-terminally ill Maryland residents. Three of those patients had co-existing clinical depression. His actions were discovered purely by accident. He was never charged or prosecuted in Maryland. He admitted in an interview with the Baltimore Sun that he had been involved in 15 suicides in Maryland and 300 nationwide (Dance 2014).

If Maryland is unwilling to enforce criminal prohibitions, the enforcement of statutory safeguards is even less likely. Connecticut's Division of Criminal Justice acknowledged that the statutory construction of their legislation would have prohibited prosecution for murder (Connecticut 2015).

3. Implications for the Practice of Psychiatry

This legislation has the potential to significantly complicate the practice of psychiatry in Maryland, for both the treating clinician and when functioning as an evaluator of decision-making capacity.

This law would carve out a class of people who theoretically could be categorically exempt from emergency evaluation procedures or civil commitment. Given that some individuals live for more than one year after receiving a lethal prescription, and that capacity may deteriorate over that time, it is unclear whether a qualified patient who has lost capacity could be assessed and treated for mental illness under this law.

There is no provision to correct an error if lethal medication is given to a patient who has concealed his or her psychiatric history from a prescribing physician. A treating psychiatrist who discovers an error would have no legal means to take custody of or dispose of the medication given to a patient. There is no procedural mechanism to challenge a faulty or erroneous capacity assessment.

A psychiatrist charged with assessing capacity must also rule out the possibility of coercion. In order to do this, the evaluator must be at liberty to interview any individual with relevant information. Under this law, a coerced individual could refuse permission for the evaluator to speak with anyone who has knowledge of the coercion.

The law allows the patient to ingest the medication at the time and place of his or her choosing. Thus, a participating facility could require an inpatient psychiatric unit to allow ingestion on the ward in violation of ward suicide prevention policies. This would be particularly detrimental on units designed for the treatment of eating disorders or in geriatric units, where it would be most likely to occur. People with mental illness also develop co-occurring serious medical conditions such as diabetes; since the law does not require the patient to accept any treatment, this condition would qualify as “terminal” if the individual refuses insulin (Oregon Health Authority 2018). California's health department regulations mandate that state psychiatric facilities must carry out assisted suicides within their units under certain conditions (9 CCR §4601).

Conclusion

Several additional deficiencies have been identified by other opponent groups, and the Maryland Psychiatric Society endorses these concerns. These include:

1.  No requirement for decisional capacity at the time of ingestion.
2.  No requirement for an independent or law enforcement observer at the time of ingestion.
3.  No mechanism to detect a negligent, incompetent, or malicious prescriber.
4.  The risk to third parties in the home (depressed or mentally ill family members).
5.  Detrimental psychological effects on the involved medical professional.
6.  No requirement for a doctor to notify a power of attorney or guardian that a prescription has been requested.
7.  Potential federal civil rights violations if the eligible person is institutionalized in a correctional facility or state hospital where prevention of suicide is an affirmative obligation.
8.  The lack of mental health screening instruments validated in this population for this purpose.
9.  No mandatory reporting or whistleblower protection for healthcare providers aware of negligent or malicious prescribers

References:

Anfang S et al. APA Resource Document on Physician Assisted Death. American Psychiatric Association 2017.

Blasco-Fontecilla, Hilario. “On Suicide Clusters: More than Contagion.” The Australian and New Zealand Journal of Psychiatry 47, no. 5 (May 2013): 490–91. https://doi.org/10.1177/0004867412465023.

California. Petitions to the Superior Court and Access to the End of Life Option Act. 9 CCR §4601 (2016).

Carmichael, Victoria, and Rob Whitley. “Media Coverage of Robin Williams’ Suicide in the United States: A Contributor to Contagion?” PLOS ONE 14, no. 5 (May 9, 2019): e0216543. https://doi.org/10.1371/journal.pone.0216543.

Colorado End-of-Life Options Act, Year One 2017 Data Summary. Available at: https://drive.google.com/open?id=1kBXgAFzHl6kcfsvtLHfOQ94Unk9mDa-  Accessed February 2, 2020

Connecticut Division of Criminal Justice. Written Testimony Regarding HB7015. 2015. Available at https://www.cga.ct.gov/2015/JUDdata/Tmy/2015HB-07015-R000318-Division%20of%20Criminal%20Justice%20-%20State%20of%20Connecticut-TMY.PDF. Accessed February 4, 2020

Dance, Scott. 2014. “Maryland Strips Doctor of License for Assisting in Six Suicides - Baltimore Sun.” Baltimore Sun, December 30, 2014. https://www.baltimoresun.com/health/bs-hs-suicide-doctor-20141230-story.html.

Death with Dignity National Center. Stories. Available at: https://www.deathwithdignity.org/stories/  Accessed February 2, 2020.

Johnson, Will. 2016 “Brittany Maynard’s Story Sends the Wrong Message to Young People.” Accessed February 2, 2020. https://www.choiceillusioncolorado.org/2016/10/brittany-maynards-story-sends-wrong.html.

Lewis, Penney, and Isra Black. “Reporting and Scrutiny of Reported Cases in Four Jurisdictions Where Assisted Dying Is Lawful: A Review of the Evidence in the Netherlands, Belgium, Oregon and Switzerland.” Med Law Int 13, no. 4 (2013): 221–39.

Marzuk PM, Tardiff K, Hirsch CS, Leon AC, Stajic M, Hartwell N, Portera L (1993) Increase in suicide by asphyxiation in New York city after the publication of Final Exit. N Engl J Med 329:1508–1510.  https://doi.org/10.1056/NEJM199311113292022

Munson, Kyle, and Jason Clayworth. 2016. “Suicide with a Helping Hand Worries Iowans on Both Sides of ‘Right to Die.’” Des Moines Register, November 25, 2016. https://www.desmoinesregister.com/story/news/investigations/2016/11/25/too-weak-kill-herself-assistance-legal/92407392/.

Oregon. Death With Dignity Annual Reports. Available at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx Accessed February 2, 2020
Oregon Health Authority. 2018. Responses to Fabian Stahle. Available at: https://drive.google.com/file/d/1XopTDjBA2SAVBGBxpDazNN899eTHixSe/view. Accessed February 4, 2020

Shreiber, J, and L Culpepper. 2020. “Suicidal Ideation and Behavior in Adults.” Up-to-Date, January. https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults.