Physician-Assisted Death for Psychiatrically Ill Patients

In a commentary published in JAMA Psychiatry, Scott Kim, Yeates Conwell, and Eric Caine discuss “suicide and physician-assisted death for persons with psychiatric disorders.” Earlier in 2018, two other commentaries on this topic were published in the New England Journal of Medicine. One was “Physician-Assisted Death for Psychiatric Patients — Misguided Public Policy” by Franklin Miller and Paul Appelbaum, and the other was “Physician-Assisted Suicide and Psychiatric Illness” by Joris Vandenberghe.

Physician-assisted death, also known as physician-assisted suicide and “Death with Dignity,” is legal in several states and the District of Columbia for persons who are suffering from painful, terminal illnesses such as end-stage cancer. The law in these states restricts its availability to individuals who have a medical prognosis of likely death within a few weeks or months.

In Belgium and the Netherlands, physician-assisted death is permitted for individuals suffering from severe, treatment-resistant psychiatric illnesses. In these cases, physicians are allowed to assist in the deaths of people who want to die because they feel that the distress caused by their psychiatric illness is unbearable. However, these individuals would not likely die soon unless their deaths were self-inflicted.

Kim, Conwell, and Caine estimate that 1–2% of physician-assisted deaths in Belgium and the Netherlands involve psychiatrically ill individuals who wish to die because of their psychiatric disorders. Currently, physician-assisted death to relieve psychiatric distress is not permitted in the United States.

In a 2016 report addressing physician-assisted death for psychiatric illness in the Netherlands, Kim and colleagues found that depression was the primary psychiatric illness in 55% of 66 persons who died in this fashion. Most also suffered from personality disorders. Seventy percent (70%) were women, and 42% were less than 60 years old. Although these individuals suffered from severe illnesses, it is unlikely that they would have died shortly other than by self-inflicted means. A number of these individuals had refused treatments that may have been helpful such as electroconvulsive therapy.

Kim, Conwell, and Caine express concern about the position of the American Association of Suicidality (AAS) regarding physician-assisted death. In a statement approved October 30, 2017, this organization indicated that physician-assisted death is not the same as suicide. Kim and colleagues are concerned that the AAS did not specifically address physician-assisted death for psychiatric disorders in distinction from physician-assisted death for terminal medical illnesses, since the boundary between assisted death and assisted suicide is likely blurred.

Physician-assisted deaths of individuals with terminal illnesses are controversial in the United States and are currently permitted in only a limited number of states. There are additional medical and ethical concerns in assisting suicide in non-terminally ill individuals with treatment-resistant psychiatric disorders, including the definition of what is meant by “treatment-resistant.” Suicidal ideation and intent can accompany all major psychiatric illnesses, and psychiatric illnesses account for over 90% of the nearly 45,000 completed suicides that occur annually in the United States. Thus, a major component of psychiatric practice involves the evaluation and treatment of patients with suicidality. As psychiatrists, we see the active assisting of suicide in psychiatrically ill individuals who have not exhausted and been compliant with all available effective treatments as misguided and just plain wrong. It fails to take into account the emotional, motivational, and cognitive dysfunction associated with all major psychiatric illnesses.

This post was written by Eugene Rubin MD, PhD and Charles Zorumski MD.