Physician‐assisted death for psychiatric disorders: ongoing reasons for concern
Authors: Paul S. Appelbaum
Journal: World Psychiatry (2024)

Physician-assisted death (PAD) – i.e., the prescription and administration of lethal medications by physicians – is increasingly available as an option for people struggling with psychiatric disorders. Although PAD was initially promoted as a means of easing suffering for people with terminal conditions, a growing number of jurisdictions have extended access to all causes of intractable and severe suffering, including psychiatric conditions. At present, Belgium, the Netherlands and Luxembourg, along with Spain and Switzerland, either explicitly authorize or de facto permit lethal assistance in such cases1. Canada is scheduled to join this group in March 2024. It is difficult to ascertain how often PAD is used for psychiatric disorders; however, among all PAD cases in Switzerland, 8% of those in Swiss residents and 17% of those in people traveling from other countries for this purpose had documented mental disorders2. Overall, available data suggest that the frequency of PAD use in people with psychiatric disorders is increasing1. A growing literature is debating the ethics of PAD in psychiatry. For jurisdictions that permit PAD in terminal illnesses, it is commonly argued that to preclude its use for non-terminal conditions that cause immense suffering, including psychiatric disorders, is discriminatory. To proponents of psychiatric PAD, it appears unquestionable that these conditions can cause severe suffering and may be resistant to available treatments, that most people with a psychiatric diagnosis are competent to decide that death is preferable to an indefinite continuation of their current state, and that clinicians can reliably ascertain whether these criteria have been met3. I have previously detailed in this journal4 my concerns about PAD for people with psychiatric disorders. Among the reasons I noted for caution in embracing PAD are its application to disorders very different from treatment-resistant depression (which is often held up as the model of an intractable condition that causes great suffering), including autism, eating disorders, dissociative disorders, and personality disorders. The high proportion of patients with personality disorders seeking PAD, and the well-known reactivity of these conditions to environmental circumstances, raise the question of just how deeply rooted the distress being expressed by such patients might be. Whether a person is experiencing severe suffering, a key criterion for eligibility, is entirely subjective, leaving evaluators with little choice but to accept the patient's assertion that this is the case. Given that intractability is usually judged only by the lack of response to those treatments that a patient is willing to accept, it is common that potentially effective interventions have never been tried by patients seeking PAD. Finally, whether the underlying disorder is driving the person's choice is very difficult to ascertain, leaving the decisional competence requirement little role to play in these cases. Here, I want to consider what we can learn from the experience with psychiatric PAD, primarily from reports published over the last five years. There has always been concern that PAD would become a replacement for the provision of psychiatric care, especially where such care is not easily accessed. Recent reports from Canada underscore this concern, as exemplified by the account of a woman who sought help at a hospital for suicidal ideation5. She was told that the mental health system was "completely overwhelmed", no inpatient beds were available, and she would have to wait six months to see a psychiatrist as an outpatient. At that point, the counselor assessing her asked if she had ever considered PAD, explained how it worked, and noted that it would alleviate her suffering. All this occurred even though PAD was technically not yet authorized in Canada for people with mental disorders, and reinforces reports from other Canadian jurisdictions. Along with concern about PAD being used as a substitute for care are data suggesting that patients who are suicidal – and thus should be treated for their intention to end their lives – are disproportionately seeking PAD. A review of studies on the prevalence of personality disorders among PAD requesters noted that in several reports they represented more than 50% of the sample; the authors underscored the substantial frequency of suicidal behavior in personality disorders, its fluctuating nature, and the existence of evidence-based treatments to address it6. Another review focused on the disproportionate use of psychiatric PAD for women, who accounted for 69-77% of cases in several series7. The authors noted that women also attempt suicide more frequently and typically favor less violent means, such as medication overdose. Hence, they suggested that PAD may be serving as a substitute for self-inflicted suicide, especially for women, and encouraged further research on this question. The momentous nature of a decision to seek PAD – an irreversible and final procedure – suggests the need for great care in evaluating whether the criteria for eligibility are met. However, this appears often not to be the case. A review of 66 cases of PAD from the Netherlands found that, in 55% of cases, documentation of decisional capacity was limited to a global judgment, without assessment of specific capacity-related abilities8. Moreover, there was disagreement about capacity among evaluating physicians in 12% of cases in which PAD was carried out anyway. The authors concluded that the decisional capacity of psychiatric patients seeking PAD receives neither a high level of scrutiny nor is subject to a high threshold, an approach that seems to be accepted by the committees that review these cases. In some jurisdictions, a patient with a psychiatric disorder need not be evaluated by a psychiatrist prior to PAD, heightening the probability of inadequate evaluation. A recent case report from the Netherlands illustrates another reason for careful evaluation: the possibility that a patient has been misdiagnosed and thus has not received effective treatment9. In this case, intolerable auditory hallucinations that motivated the request for PAD were found to be due to intrusive thoughts and responded to cognitive-behavior therapy. The authors recommend an "obligatory second opinion by a psychiatrist specialized in the patient's disorder", which is not currently required. Where does this leave us? These data suggest that many of the initial worries about psychiatric PAD are being reinforced by ongoing practice. This procedure is susceptible to being used as a replacement for care; it appears to be sought by patients, especially women, as a substitute for trying to end their own lives; and the challenging evaluations of the required criteria seem often to be performed in a perfunctory manner. Although data are not yet available, it is worthwhile thinking about the longer-term impact on psychiatrists and psychiatric patients: the message that their conditions may be hopeless, thus not worth the effort to treat or to receive treatment, and that death is an acceptable alternative. Such a posture conflicts with the traditional stance of psychiatry as a specialty dedicated to sustaining hope, protecting people from the impulse to end their lives, and helping people find meaning in their existence. The prospect of further spread of psychiatric PAD is indeed reason for concern.