In January, Kevin Drum wrote a widely-read article about his plan to take his own life before he succumbs to cancer. Drum didn’t make an argument for the right to assisted suicide. Perhaps this is because he didn’t need to. As of January 1st, he has that right under California law. What he did, with grace and clarity, was to describe his situation and his motivation for this plan.
What I admire most about Drum’s article is how he carefully surveyed concerns that marginalized populations might commit suicide rather than being offered appropriate health care. These concerns must be taken seriously. I will look specifically at new data from the Netherlands about assisted suicide and the mentally ill.
Drum has multiple myeloma. Here’s what he sees ahead:
Sometime in the next few years… there will be no more treatments to try. My bones will become more brittle and may break or accumulate microfractures. My immune system will deteriorate, making me vulnerable to opportunistic outside infections. I may suffer from hemorrhages or renal failure… Multiple myeloma can end in a lot of different ways. But one thing is sure: Once any of these symptoms start up, I’ll be dead within a few weeks or months.
Drum sees no reason
to let that happen… I don’t want to die in pain—or drugged into a stupor by pain meds—all while connected to tubes and respirators in a hospital room. When the end is near, I want to take my own life.
And he would like help from a physician to do a good job of it.
This is the classical best case for the right to assisted suicide: a terminal illness, the likelihood of a terrible death, and a highly competent, socially-connected, and otherwise happy patient expressing a stable, well-considered intention to die. If this man wants to end his life to preserve his dignity, who are we to deny him?
But what about people who face intense suffering, but who may lack Drum’s lucidity, self-possession, and warm family support? In JAMA Psychiatry, Scott Kim and his colleagues looked at psychiatric patients in Holland who died through euthanasia or assisted suicide (EAS).
DESIGN, SETTING, AND PARTICIPANTS. This investigation reviewed psychiatric EAS case summaries made available online by the Dutch regional euthanasia review committees as of June 1, 2015. Two senior psychiatrists used directed content analysis to review and code the reports. In total, 66 cases from 2011 to 2014 were reviewed.
MAIN OUTCOMES AND MEASURES. Clinical and social characteristics of patients, physician review process of the patients’ requests, and the euthanasia review committees’ assessments of the physicians’ actions.
RESULTS. Of the 66 cases reviewed, 70% (n = 46) were women. In total, 32% (n = 21) were 70 years or older, 44% (n = 29) were 50 to 70 years old, and 24% (n = 16) were 30 to 50 years old. Most had chronic, severe conditions, with histories of attempted suicides and psychiatric hospitalizations. Most had personality disorders and were described as socially isolated or lonely. Depressive disorders were the primary psychiatric issue in 55% (n = 36) of cases. Other conditions represented were psychotic, posttraumatic stress or anxiety, somatoform, neurocognitive, and eating disorders, as well as prolonged grief and autism. Comorbidities with functional impairments were common. Forty-one percent (n = 27) of physicians performing EAS were psychiatrists. Twenty-seven percent (n = 18) of patients received the procedure from physicians new to them, 14 of whom were physicians from the End-of-Life Clinic, a mobile euthanasia clinic. Consultation with other physicians was extensive, but 11% (n = 7) of cases had no independent psychiatric input, and 24% (n = 16) of cases involved disagreement among consultants.
Kim et al. also found that 52% of these patients had prior histories of suicide attempts. In any other situation, a mentally-ill person’s expression of a plan to commit suicide should trigger urgent efforts to prevent that act.
In an editorial accompanying the Kim’s article, Paul Appelbaum notes that Dutch patients’ intentions to commit suicide were not always stable.
38% of the Belgian patients who asked for physician assistance withdrew their requests to die before the evaluation could be completed.
In one in four cases, physicians disagreed about whether the criteria for assisted suicide were met, and half of those (8 of 16) disagreements were about the patient’s competence to decide. Kim et al. report that
Twenty-one patients (32%) had been refused EAS at some point. In 3 patients, the physicians changed their minds and later performed EAS. In the remaining 18 patients, the physician performing the EAS was new to the patient. In 14 cases, the new physician was affiliated with the End-of-Life Clinic, a mobile euthanasia practice.
Appelbaum comments that
It is particularly troubling that in 12% (8 of 66) of cases the psychiatrist involved believed that the criteria [for assisted suicide] were not met, but assisted death took place anyway.
56% of patients were reported to be lonely or socially isolated. And finally, why were 70% of these patients women?
Overall, these patients were not like Kevin Drum. Appelbaum observes that
The practice of helping patients to die began with patients having terminal illness, often with metastatic cancer, who have a limited life span and are experiencing severe pain. For those patients, the application of the criteria for assistance—including a terminal diagnosis, competent decision, and intense suffering—while not easy in every case, is relatively straightforward. For psychiatric patients, however, for whom a desire to die is often part of the disorder…, the competence of their decision and the intractability of their suffering are much more difficult to assess.
These data on Dutch psychiatric patients raise concerns about the practice of assisted suicide, but they do not make a conclusive case against it. There are several possible ethical and policy responses to these data. Perhaps permitting physicians to help these psychiatric patients to take their lives is the right choice. Or perhaps it isn’t, and jurisdictions should simply establish criteria for physician-assisted suicide that exclude the mentally ill. Perhaps Drum should have the right to end his life on his own terms, regardless of the risks this poses to others. In the next post I will discuss the challenges these data pose for bioethics.