The New England Journal of Medicine has two new “op-ed”-style pieces raising concerns about extending physician-assisted suicide (PAS) from people with end-stage terminal illness to people who may express a desire to die because of (non-terminal) mental illness. (Regrettably, both require subscription access.) PAS in these cases is being exercised in Belgium and the Netherlands, and is being considered in Canada
In one article, the authors label PAS for psychiatric patients “misguided public policy,” Although patients may be suffering terribly from, say, severe depression, they may be victims of “distorted cognition” that leads them to see their lives as worthless. This, the authors argue, is a manifestation of the mental disease—so, in a sense, it’s not “healthy” or “real” (my words, not theirs). In essence, the patient is not somehow mistaken about his suffering—rather, it’s potentially treatable. Unless in some cases it’s not, I suppose, in which case it’s not clear how the authors would resolve that. Oh, and in the absence of universal health insurance (a problem that the Dutch and Belgians and Canadians all avoid, they allow), some miser might see PAS as a convenient way to save a few bucks—or quite a few, for that matter.
Some suicidal psychiatric patients may indeed make “rational and autonomous” (the authors’ phrase, not mine) decisions for PAS, but doctors might make diagnostic mistakes and “let other patients slip through.” Must such mistakes be accepted, as a sort of “collateral damage” for an otherwise desirable policy? No, the authors say; to allow PAS for psychiatric patients contradicts “physicians’ commitment to preserving life and preventing suicide.” To this last point, I might offer an “Amen.”
In the other article, a Dutch doctor argues that there, and in Belgium, the PAS regime is simply too lax. For PAS to be ethical, he argues, it must be a last resort. But no such safeguards are in place there, and, indeed, eligibility for one form of treatment—deep brain stimulation—requires a more stringent evaluation than PAS does. The author of this article would permit PAS for psychiatric patients not only if all treatment options had been considered, but “only if the patient had not refused a reasonable treatment option” (emphasis mine).
So much for autonomy, I guess. Back to a (welcome?) paternalism that recognizes the doctor’s calling is first to care for and preserve life?
The second author concludes that PAS should be considered only in parallel with “recovery-oriented care,” to ensure “that there is a treatment advocate involved, [that PAS is not] used as an escape for an overwhelmed physician, and [that] the focus of care [is not] narrowed down to death.”