Assistance in Dying: Deepening Understanding of Novel Ethical Issues in Psychiatry

Assistance in dying for individuals who will soon succumb to a terminal illness is a topic that has been debated for decades in college classes, in medical school lecture halls, in ethics committee conference rooms, in state legislative sessions, and on the covers of popular magazines. Traditional arguments against assisted-death practices have focused on the sanctity of life and the role of physician as healer. Arguments for assisted-death practices have highlighted the salience of compassion, autonomy, dignity, and, occasionally, the scarcity of health care resources. Until recently in psychiatry, assistance in death has been eschewed as essentially irrelevant: the illnesses our profession cares for are not “terminal,” and our efforts are dedicated to prevention of early death—not the opposite.

And yet, assisted suicide and euthanasia practices have entered the repertoire of physicians, including psychiatrists, in many countries in Europe. In this country, assisted suicide has been decriminalized in several states, and assisted-death legislation was adopted in Canada in June of this year. The conditions under which assistance in death are considered acceptable, or at least not criminal, in these varied places throughout the world are expanding. No longer is assistance in dying by physicians delimited to those near the very end of their lives due to a devastating physical illness. Assistance in dying definitions and guidelines have stretched to include conditions considered futile, including some neurocognitive, intellectual, and mental disorders, for example. A recent longitudinal report from Belgium indicates that out of 100 patients who requested euthanasia for psychological suffering associated with chronic, but not necessarily life-threatening, mental disorders, 35 had had their request carried out over the five-year period of the study.

Intentional hastening of death is absolutely unethical, according to the AMA and, following suit, APA. Empirical studies of physician attitudes toward assisted-death practices are not uniformly in support of this ethical stance. In a very early study I performed with colleagues, we found that consultation-liaison psychiatrists and psychosomatic medicine physicians were unwilling to perform assorted death procedures personally but were somewhat more accepting of other physicians’ involvement.

In a second small study we conducted involving resident physicians, we found residents in internal medicine, emergency medicine, and psychiatry were not supportive of assisted-death activities, with psychiatric and internal medicine residents in greatest opposition. Larger empirical projects suggest that Oregon physicians do provide prescriptions of lethal medications that result in patient suicide.

While public opinion shows support for assistance in dying, studies of physically and mentally ill individuals have revealed more nuanced results. A number of studies of seriously ill individuals make clear that their hopes and requests pertain to relief of pain and optimal quality of life. Moreover, these studies have found no differences in unbearable suffering between patients who requested aid in dying and those who did not, although patients who also suffered from a depressive disorder were more likely to submit a request and more likely to change their minds within a few months. Polls of the general public indicate that even active euthanasia practices by physicians would be seen as acceptable by large numbers of adults in the United States.

Even within the House of Medicine, with its clear ethical stance, we are divided on the profound and fundamental issue of how we define the role of the physician. Do we help our patients bear their suffering—not turn away—and ease their burdens where we can? Do we stand with our patients as they live with illness and also as they eventually and often tragically confront their deaths? Do we protect our patients when they are at their most vulnerable and in great pain? Or do we act on their wishes, or the wishes of those to whom their lives have been entrusted?

In psychiatry, perhaps more than any other discipline in medicine, we should understand how good health and recovery may return, even after very serious episodes of illness. We should understand how vulnerability can be exploited. We should understand how wishes that are expressed may be transient or a reflection of compromised decisional capacity, despair, or distress that may lessen or reverse with treatment, emotional support, and the passage of time. We also should understand how disparities in the distribution of health resources greatly determine health care and health outcomes, with individuals with mental disorders often least able to advocate for themselves and protect their well-being and interests in society. The field of psychiatry for these reasons has an important perspective to offer to the world’s discussion of the ethical acceptability of assisted-death practices by physicians, whether in relation to individuals with mental and other medical illnesses.

Deepening one’s understanding of ethical issues, such as assistance in dying, and applying this understanding as an astute psychiatric practitioner are more than mere intuition, years of experience, or innate good judgment. A well-developed skillset is needed: the ability to recognize moral and values-laden aspects of an issue, the ability to seek additional information or counsel that will help resolve ethical tensions that exist, the ability to evaluate choices for their ethical intent or outcomes, and the ability to safeguard against actions that have irreversible and negative ethical consequences—these are all important clinical ethics skills. These skills are grounded in the rich multidisciplinary scholarship of biomedical ethics and its ever-growing base of empirical evidence. Clinical ethics skills are learned and taught intentionally. Moreover, wise practitioners appreciate that these capabilities require openness, self-observation, and practice to become integrated within one’s therapeutic inventory to bring benefit to patients and to enhance the standard of care they receive.

Each new day brings encounters with people with serious illnesses whose care presents new ethical questions and challenges. Each new clinical practice approach, each new technological development, and each new social policy creates complex, seemingly unprecedented, and irresolvable dilemmas. Assisted-death practices, including assisted suicide and euthanasia, now being adopted widely throughout the world and increasingly affecting the lives, and deaths, of people with mental illness represent one such novel ethical dilemma.

Traditions, codes, and legal rulings may feel insufficient and, applied in rote fashion, will offer little support in such difficult situations. These situations represent an invitation for deepened understanding and for the development of greater and more sophisticated ethical skills—and, indeed, they define the real meaning of professionalism in the care of human suffering. ■