The Debate Over Psychiatric Suffering and Physician-Assisted Death

by Eugene Rubin, MD, Ph.D., and Charles Zorumski, MD.

Physician-assisted death (PAD) is legal in many countries as well as in 10 states and the District of Columbia in the United States. The initial intent was to help patients suffering from painful, terminal illnesses die on their own terms. Increasingly, though, PAD is being considered for and offered to individuals with intractable, severe suffering, even if their medical conditions are not terminal. In some countries, PAD is now available for those suffering from psychiatric disorders as well.

Already Permitted in Some Countries

Paul Appelbaum recently published a commentary addressing PAD for psychiatric illnesses in the journal World Psychiatry. Appelbaum is a professor at Columbia University and a renowned forensic psychiatrist and ethicist as well as past president of the American Psychiatric Association. He reports that PAD purely for psychiatric conditions is an option in several countries, including Belgium, the Netherlands, Luxembourg, Spain, and Switzerland, and is scheduled to begin in Canada in March 2024.

What psychiatric conditions have been associated with PAD? Treatment-resistant depression is the most common, but other disorders include personality disorders, autism, and eating disorders. Many individuals with treatment-resistant depression also suffer from concurrent personality disorders. Symptoms often fluctuate markedly in individuals with personality disorders and are strongly influenced by life stressors.

Appelbaum summarizes the reasoning behind PAD for psychiatric conditions as follows: “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 met.”

Several Concerns

Appelbaum discusses several concerns with allowing PAD for psychiatric conditions. He notes that there is a shortage of psychiatric services in general and so PAD may be offered as an alternative to the lack of available care. He is concerned that patients with suicidal tendencies may be encouraged to consider PAD instead of receiving treatment to alleviate suicidal thoughts and behaviors. Some psychiatric patients who request PAD may be unwilling to undergo potentially helpful treatment. He further reports that the careful evaluation and screening protocols involving psychiatric patients being considered for PAD are not always followed: “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.”

There are many difficulties in evaluating and treating persons with chronic, painful psychiatric disorders. Some patients have dramatic symptoms, and their behaviors can frustrate providers who lack expertise in treating such individuals. As psychiatric treatment centers are often overwhelmed and care for such patients may be hard to find, offering PAD for psychiatric conditions is concerning.

In our opinion, there needs to be a high bar that ensures both careful evaluation and appropriate treatment prior to offering PAD to psychiatric patients. Recently, new treatments for suicidality and depression have become available, and it is likely that more will be available in the near future. Checks and balances need to be in place and enforced to prevent premature PAD. Society has not been the most supportive of those suffering from mental illness, and stigmatization remains a significant problem. Decisions to accept a request for PAD should not be based on frustration with health delivery systems or with the sometimes dramatic, but fluctuating, symptoms exhibited by patients. After all, we are talking about facilitating the taking of a life. Once done, it can’t be undone.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the 988 Suicide & Crisis Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.