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).

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)

Can ‘assisted dying’ ever be fully autonomous?

This article was published by Bioedge on October 30, 2021.

By Michael Cook

Respect for autonomy, even more than fear of pain, is the fundamental reason why the argument for “assisted dying” has been so powerful. But will a decision to deliberately choose death ever be fully autonomous?

In an impressive article in Psychiatric Times, two psychiatrists, Ronald Pies and Cynthia Geppert, make a persuasive case that it is not. (Hat tip to Alex Schadenberg.)

They advance several reasons for criticising what they call “the autonomy myth”.

(1) Administrative. Patients are still caught up in a web of procedural requirements – diagnosing their illness, confirming the diagnosis, deciding whether they are truly terminally ill, writing the prescription, etc. It is more an exercise of the physician’s autonomy. “The entire process of PAS is critically dependent on the authority of powerful others who must approve (or veto) every decision along the way,” they write.

(2) Autonomy is only one of the four universal and basic ethical principles in contemporary bioethics. The others in the widely used approach of principlism, are beneficence, non-maleficence, and justice. Autonomy dominates in a consumer society. However, autonomy, as a principle of medical ethics, has a markedly Anglo-American cast. It makes an uneasy fit with other cultures, notably indigenous peoples and Latinos, especially for end-of-life decisions.

(3) The laws framed to legalise assisted suicide in the US do not take family dynamics into account when assessing whether the patient is making a truly autonomous decision. Nor do they assess autonomy at the moment of taking the lethal medication – which is the moment which matters.

(4) Rational autonomy has both a cognitive dimension and an emotional dimension. Patients who are fully aware of what they are doing may have a distorted view of reality. Cancer patients, for instance, might make erroneous assumptions like, “No one can help me,” or “No one understands what I am going through.” Absence of clinical depression does not exclude demoralisation and hopelessness. “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.”

Article: Assisted suicide and the autonomy myth. Do patients really have rational autonomy? (Link).

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.

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).