Physician Aid-in-Dying: Role of Psychiatrists

At APA’s September Component Meetings, I attended a discussion related to physician aid-in-dying (PAD; Psychiatric News, October 16). I learned that PAD is the preferred term to “physician-assisted suicide.” It was explained that PAD is not euthanasia, nor is it withdrawing or withholding care. PAD is also not “sedation for the imminently dying,” where the purpose is not to hasten death (although this may occur). Rather, PAD involves a physician prescribing a lethal dose of medications to terminally ill patients, and the patients, at some later time, administering the medications to themselves. To qualify for PAD, a patient must be “terminal,” defined as having six months or less to live (the same definition used by Medicare for eligibility for hospice care).

What does this have to do with psychiatry? Most of the current PAD laws say that if either the primary physician or consulting physician “believes the patient’s judgment is impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination” (Oregon’s Death With Dignity statute). Thus, according to these PAD laws, psychiatrists may be asked to conduct examinations. For example, in Oregon from 1997 to 2013, 47 patients were referred for psychiatric examinations. In 2014, of the 105 patients who requested PAD, three were referred for psychiatric examinations.

There are PAD statutes in Oregon, Washington, Montana, Vermont, and California (signed into law in 2015). In 2014, legislatures in at least six other states considered proposals. Gallup polls have shown that between 1998 and 2012, there has been increasing support of PAD by members of the public, especially when the question is framed as “Does a physician have the right to help patients end their lives by painless means?” (as opposed to “Does a physician have the right to help patients commit suicide?”)

A recent survey of members of the American Academy of Neurologists showed that most members felt that PAD is ethically permissible in certain circumstances and should be legally permitted. This position may partially be because neurologists treat patients with amyotrophic lateral sclerosis (ALS).

A survey of members of the California Psychiatric Association (CPA) found that California psychiatrists had differing opinions about PAD and that there was no clear consensus for or against it. When the PAD statute was introduced in the California legislature this year, the CPA did not take a position on it.

While APA does not have an official position statement about PAD (although it does support palliative care), the AMA has a clear position that participation in PAD is unethical. AMA Opinion 2.211 states: “Allowing physicians to participate in assisted suicide would cause more harm than good. 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.”

Other opponents to PAD include some disability rights groups and religious groups such as the Catholic Church. Arguments against PAD include concerns that PAD could be inappropriately used to contain medical costs, that PAD would be preferentially applied to disenfranchised and poor patients and, in the case of the Catholic Church, no steps should be taken to end a life.

PAD has been legal in Oregon since 1997 and Oregon’s experience has not confirmed most of the fears about the abuse of PAD. Data from Oregon show that as of 2014, 1,327 people got prescriptions, and interestingly, only 859 used them. PAD deaths account for 31 of every 10,000 deaths. Most of the patients requesting PAD had cancer; the second most common diagnosis was ALS. The three most frequent reasons for requesting PAD were loss of autonomy, decreasing ability to participate in pleasurable activities, and loss of dignity. The median age of the patients was 69. Most were white and educated, and most were in hospice and had insurance.

Even though APA does not have a position about PAD, psychiatrists are being given a role in the practice of PAD. The discussion at the September Component Meetings centered on whether APA should prepare a resource document to give guidance to our members who may be asked to do psychological evaluations of patients who request PAD. For example, the resource document might address these questions: What are the factors that need to be considered in doing such evaluations? What are the criteria for competence? If someone is depressed, especially in the context of having a terminal illness, can he/she still be competent to request PAD? What are the ethical challenges to doing such evaluations? Do we think that one psychological evaluation is adequate? Who should provide the oversight?

As the number of PAD statutes is likely to increase, APA has the opportunity in shaping how these statutes are written and delineating our roles. ■