Physician-assisted death in psychiatry
Authors: Paul S. Appelbaum
Journal: World Psychiatry (2018)

Physician-assisted death (PAD) – a term encompassing both the prescription and administration of life-ending medications – originated as a response to the extreme physical suffering of many people with terminal conditions such as cancer. Given that their lives would soon end in any case, allowing them to avoid the pain associated with their final days was seen as consistent with physicians' obligations to relieve suffering. Persuaded by such arguments, at least six countries and five US states have legalized some form of PAD1. However, Belgium, the Netherlands and Luxembourg have gone a step further, eliminating the requirement for a terminal illness, thus making people with psychiatric disorders eligible for physician assistance in ending their lives – a move currently under consideration in Canada as well1, 2. Supporters of PAD for psychiatric disorders argue that denying access to relief from suffering to persons with such conditions is discriminatory, reflecting a failure to recognize the real pain associated with depression, chronic psychotic disorders, and other psychiatric illnesses3. In Belgium and the Netherlands, clinics have been established to facilitate access to PAD, and the use of the procedure is increasing. The most recent Dutch data (from 2015) indicate that approximately 4.5% of all deaths are due to PAD, with psychiatric disorders accounting for 3% of the total4. Belgium has a similar proportion of PAD deaths involving persons whose suffering is primarily attributable to psychiatric disorders2. In light of the growing use of PAD for psychiatric indications, it is worth considering why other jurisdictions may want to exercise caution about embracing this trend. Although advocates for psychiatric PAD often take treatment-resistant depression as the model disorder for which termination of life may be indicated, it seems clear that PAD is being used for many other disorders as well. A study by Kim et al5, based on a sample of 66 reports filed with the Dutch entity charged with overseeing PAD, found that 49 cases involved depression, but six were reported to have substance abuse, four neurocognitive impairment, and two autism spectrum disorder. A review of 100 persons requesting PAD in Belgium6 reported that 90% had multiple psychiatric conditions, with 58% suffering from mood disorders, at least 12% from Asperger's syndrome, 10% from eating disorders, and 7% from dissociative disorders. Both the Dutch and Belgian studies reported that about half of patients requesting PAD had personality disorders, including 27% with borderline personality disorder in Belgium. The substantial presence of comorbid personality disorders, often highly reactive to life stresses, especially interpersonal conflict, raises the question of whether PAD may be sought impulsively, as a response to social distress and disappointment. Along those lines, in 56% of the Dutch cases, social isolation or loneliness was reported5. Indeed, a recent study by one of the leading advocates of psychiatric PAD in Belgium, examining the explanations by 26 patients of their requests, reported frequent comments related to social isolation, interpersonal conflict, and socio-economic stresses – all potentially remediable and none usually considered good reasons for ending one's life2. Difficulty in applying the core eligibility criteria for PAD to psychiatric disorders may contribute to its use in questionable cases8. The Belgian statute, for example, requires that persons receiving PAD have "unbearable and untreatable" disorders6. Whether a condition is unbearable, is not easily susceptible to objective determination; there seems to be little alternative to taking the patient's assertion at face value. However, depression and other psychiatric disorders are often associated with hopelessness and helplessness that heighten subjective distress. Thus, the perceived intolerability of suffering may itself be a symptom of the underlying disorder, rather than reflecting an independent judgment of the patient. In any case, the criterion offers no real basis on which a psychiatrist can judge the reasonableness of a person's request for PAD. Most of the work of determining whether an applicant qualifies for PAD, then, must be done on the basis of the requirement that the psychiatric disorder be "untreatable" (or in the Dutch law, that there be "no prospect of improvement"). Few patients will have tried every possible pharmacological, psychotherapeutic, or other treatment option (e.g., electroconvulsive therapy), and it is always difficult to judge whether some as-yet-untried approach might be helpful. However, PAD laws generally also stipulate that only treatments acceptable to the person seeking PAD should be considered in determining treatability. Thus, untreatability also becomes a subjective determination made by the person requesting PAD, who – perhaps in the grip of depressive hopelessness – can simply conclude that nothing is likely to work and thus no untried options are acceptable. Although patients must be competent to request PAD, even the most skilled of psychiatric evaluators will find it difficult to ascertain the extent to which the patient is making a judgment independent of the influence of the psychiatric disorder itself. This is particularly true for depression, in which the desire to end one's life is a common manifestation of the disorder. Other than for flagrant psychosis, which seems barely represented in the cases reported to date, the competence requirement will provide little check on the use of PAD in psychiatry. Jurisdictions considering adoption of PAD for psychiatric disorders would be well-advised also to consider the potential, less tangible impacts of legalization. Psychiatrists and other treaters may perceive PAD laws as offering "permission" to give up on treating difficult cases. It is not unimaginable that we will see frustrated psychiatrists and families under stress suggesting PAD to problematic patients as their only option. Likewise of concern is the implicit message communicated to patients when PAD becomes available, i.e., "there are hopeless conditions in psychiatry, and you may have one". Finally, one cannot ignore the temptation for countries with inadequate psychiatric care systems to look to PAD as a substitute for investment in appropriate treatment, especially for more challenging cases. Taken as a whole, there appear to be ample reasons to conclude that adoption of PAD for psychiatric disorders is likely to yield more harm than good, a judgment reflected in the American Psychiatric Association's position that "a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death"9. Paul S. Appelbaum Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York, NY, USA