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Assisted Suicide – Some Psychiatric Considerations

Dignity in Dying or Voluntary Euthanasia?

Dr Pravin Thevathasan

When the ‘Voluntary Euthanasia Society’ changed its name to ‘Dignity in Dying’, there appears to have been a tacit recognition that the voluntary nature of the moral act of mercy killing is secondary to the principle of the dignity of the human person – at least for the advocates of assisted suicide.  This may help explain why Sarah Wooten of “Dignity in Dying” stated that in both the Gilderdale case and the Inglis case, the ‘existing law doesn’t work in practice’ (1).  In the case of Gilderdale, a mother helped her daughter who had been suffering from ME for several years to commit suicide at the daughter’s own request and in the case of Inglis, a mother killed her son who did not have the capacity to make such a request owing to the degree of brain damage he had sustained.  Gilderdale was found not guilty and Inglis was found guilty and given a 9 year prison term. 

It is entirely logical for the once ”voluntary euthanasia society” to consider both cases as morally equivalent and for both mothers to be treated with lenience.  As long as both mothers acted out of compassion, surely, they  argue, there can be no moral distinction to be made between the two cases.  As the Royal College of Psychiatrists put it in their statement on ‘Assisted Dying for the Terminally Ill’: ‘Why should one limit assisted suicide to people with mental capacity?  If one is trying to prevent suffering, why not allow it to be used for people with a range of psychiatric disorders?’ (2).

The bioethicist Raanan Gillon gives the scenario where an act of intentional killing seems to be intuitively acceptable.  “During the Falklands war a soldier was reported to have shot his trapped comrade in response to his comrade’s anguished plea that he was burning to death …”  (3)

But let us suppose that this same soldier then came across another comrade whose injuries were so severe that he was incapable even of requesting death.  Is the soldier not under a certain moral obligation of shooting this second comrade?

Let us further consider the case of a severely injured comrade who has undergone rehabilitation but who consistently believes that he no longer has a life worth living.  Is his case any different to that of Daniel James, a 23 year old rugby player who was paralysed from the waist down following an injury but who was not terminally ill and who ended his life in Switzerland?  If assisted suicide is available for the terminally ill, then why not for those with severe disabilities as we now appear to live in a society that increasingly assumes that severe disability is worse than death?  Unsurprisingly, the Royal College of Psychiatrists comes to the conclusion that it is impossible to limit assisted suicide to people with limited life expectancy or those with capacity to make such a choice.

The Case of Oregon

The legal expert Wesley Smith highlights a case which took place in the State of Oregon, USA, where assisted suicide is legal.  A patient named Michael Freeland was issued his lethal prescription of drugs two years before he died of natural causes, even though in Oregon it is required for a doctor to believe that a patient will die within six months from the time the prescription is given.  He was also allowed to keep his lethal medication with him even after having been diagnosed with a depressive disorder for which he was hospitalised and declared mentally incompetent by a Court.  (4).

A team of Psychiatrists have, in fact, assessed patients who wanted to make use of the assisted suicide legislation in Oregon and concluded that one in four patients had undiagnosed clinical depression.  In 2007, not one of the people who died by lethal injection in Oregon had been evaluated by a Psychiatrist or Psychologist (5).

Alzheimer’s Disease

There is a certain irony about the fact that Sir Terry Pratchett, who suffers from Alzheimer’s Disease, called for assisted suicide to be made legal at a time when Dr Els Borst, the former Health Minister who guided the liberal euthanasia law through the Dutch Parliament, has admitted that euthanasia and assisted suicide were brought in ‘far too early’ without sufficient safeguards for those who wish to die naturally.  She further notes that the legislation has led to a steep decline in medical care for the terminally ill.  “In the Netherlands, we first listened to the political and societal demand in favour of euthanasia”.  (6).

What is of further concern is that, while there are many excellent nursing homes looking after people with dementia, there are others that are understaffed, with high rates of staff turnover and poor staff morale.  The prevalence of dementia within our population has been underestimated and services are not sufficiently well resourced.  Unless we improve care standards for people with dementia, the demand for assisted suicide is likely to increase for all the wrong reasons even from the perspective of those who believe in assisted suicide and voluntary euthanasia.  Governments looking to reduce their financial burdens might be tempted to see assisted suicide as a means of cost cutting.  Writing in the ‘British Journal of General Practice’ an argument for voluntary and non-voluntary euthanasia is made largely on grounds of scarce health resources: ‘many old people do not wish for further longevity after they have become too disabled to be of service to their families and would prefer to see limited resources used for the young’. (7).  The conclusion is that families ought to be able to decide what happens to their disabled elder members in order to free resources to care for their younger members.  It is naturally assumed that families will always be motivated by compassion.  However, “compassion” is a psychological motive which is difficult to verify in law.  Might not families be motivated by less compassionate reasons such as the desire for financial benefits?  Are not families in a position to manipulate the elderly into believing that they are a burden to others?  Elder abuse within families is far from uncommon. 

The Royal College of Psychiatrists rightly asked why one ought to limit assisted suicide only to the dying?  If a patient has been diagnosed with Alzheimer’s disease and sees no useful purpose of living further, then why not offer him assisted suicide?  If, for physical reasons, he is incapable of committing suicide himself, why not offer him euthanasia?  Otherwise, one might be accused of discriminating against the incapable.

Psychological Assessments of the Chronically Ill

Mrs Gilderdale was treated by the media and by the presiding judge with enormous and understandable sympathy and she has apparently become an advocate for the euthanasia movement.  But there is, in fact, very little known about this particular case.  According to a friend and neighbour, Mrs Gilderdale’s daughter suffered from a ‘reactive depression’ brought on by chronic ill health.  Was this depression adequately treated?  Mrs Gilderdale rarely went out because her daughter was ‘too ill to be left alone’.  Were adequate respite provisions made available in this case?  How certain can we be that the daughter did not feel that she had become a burden to her only carer?  In the last years of her life, she suffered ‘appalling treatment in hospital’ when a simple operative procedure went badly wrong and, understandably, she never wanted to be hospitalised again.  Was she offered appropriate counselling on this issue?  When attempting to kill herself, she ‘banged on the partition wall and begged for help’.  Is this typical of an act of rational suicide or was there an element of desperation in this behaviour?  Was there, in fact, a systematic failure in the provision of care in this case? (8)

How good are medical practitioners in diagnosing depression in such complex cases?  How reliable is the assessment of capacity in such cases?  Is it even appropriate for psychiatrists to work on suicide prevention and at the same time take part in proceedings that may lead to assisted suicide? 

It would appear that Mrs Gilderdale acted out of compassion.  However, as already stated, compassion is a psychological motive that is both complex and difficult to prove objectively.  Wesley Smith cites the now famous case of the Manhattan assisted suicide of Myrna Lebov in 1995.  Lebov’s husband, George Delury, admitted to the offence of assisting at the suicide of his wife at her request because she was suffering from Multiple Sclerosis.  It appeared as if Delury had acted purely out of compassion and he was praised by the media, appearing on television and speaking at a convention of the American Psychiatric Association.  He even signed a book deal entitled ‘But what if she wants to die’.

Unfortunately for Delury, he had decided to keep a personal diary of the events that led to his wife’s death.  It soon became clear that he had no wish to put her out of her misery, but to be put out of his own.  Lebov, it appeared, did not have a long stated desire to die but did express occasional suicidal ideation as is common of the chronically ill.  It was her husband who had been working consistently at destroying her wish to live by making her believe that she had become a burden to others and especially to himself.  With the diary’s publication, Delury’s ‘compassion’ defence was regarded as worthless and he was given a prison term.  (9)

Studies using systematic assessments in terminally ill patients have shown that depression is strongly associated with the desire for a hastened death, including the wish for physician assisted suicide or euthanasia.  This is true for the top three diseases for which patients request physician assisted suicide: Cancer, Motor Neurone Disease and HIV/AIDS (Achille and Ogloff 2004, Block 2000, Block and Billings,1994.  Breithart et al, 2000, Chochinoo et al 1995.  Emanuel et al, 1996.  Emanuel, Fairclough and Emanuel, 2000.  Ganzine et al, 1998).  All these studies are cited in the statement by the Royal College of Psychiatrists.

The Royal College of Psychiatrists notes that once a person’s depression is treated effectively, most (98 – 99%) will later change their minds about wanting to die (Hawton and Faggs 1998).  Pain and desperation generally underlie suicidal thoughts which can be relieved by appropriate support and psychiatric treatment as well as appropriate pain relief which often lifts depressive ideation.  It is noted that in requests for physician associated suicide, the influence of a psychiatric condition in making the request can be underestimated (Bannink et al, 2000).

Conclusions

With high standards of palliative care on offer, there need never be legislation for assisted suicide.  A leading specialist in the field of Oncology, Professor Karrol Sikora, has stated: ‘In all my 37 years as a Cancer doctor, I have never had a patient who asked for euthanasia.’  (10)

Assisted suicide discriminates against the vulnerable and the disabled.  If a healthy woman attempts suicide, she is likely to receive an urgent psychiatric assessment.  If a patient with a long history of ME or MS attempts suicide, she is likely to receive sympathy and a lethal cocktail of drugs, if the appropriate legislation is in place.

A small number of individuals including various celebrities are determined to end their lives at the time of their choice.  Let them not be responsible for the demise of the most vulnerable individuals in our society.  Psychologists have long recognised that in highly constrained circumstances, vulnerable groups such as the elderly and learning and physically disabled, exhibit compliant behaviour and comply with the dominant group.  Thus when professionals raise the option of euthanasia or assisted suicide, people in this group are likely to perceive that their lives are deemed no longer worth living and that they would be better off dead.

The request for euthanasia or assisted suicide in the vulnerable is likely to be due to a complex set of reasons, for reasons of health and social conditions such as poverty, poor housing, loneliness and family pressures.  It is thus not up to a doctor to determine who should live and who should die.  Good medical practice has shown that much can be done to improve the care of the dying and the chronically ill.  It is therefore good medical practice as well as respect for the most vulnerable in our society that is the way ahead.

References

(1)  Sarah Wootton - Only clearer laws can bring compassion to the euthanasian debate - The Independent

(2)       The Royal College of Psychiatrists (2006) “Statement from the Royal College of Psychiatrist on Physician Assisted Suicide”.

(3)       Gillon, R. (1994) Philosophical Medical Ethics. John Wiley. Pg 131.

(4)            www.wrtl.org/assistedsuicide/personalstories.aspx

(5)            Dying of hopelessness: A case against assisted suicide

(6)           Regret for legalizing euthanasia expressed by former dutch official

(7)       Bliss, M (1990) “Resources, The Family and Voluntary Euthanasia. British Journal of General Practice” 40: 117-122

(8)            Gaisford, S (2010) “I don’t think what she did could be considered sinful”.  The Tablet (30th January 2010) pg 8–9

(9)    Delury - assisted suicide - First Things   Scroll down to find article
called: "Abandoning the Vulnerable in the UK to Assisted Suicide Abuse"
    


(10)           
www.dailymail.co.uk


This review first appeared in the November 2010 issue of the Catholic Medical Quarterly and is reproduced with permission.


            
Copyright ©; Dr Pravin Thevathasan 2010

Version: 20th November 2010



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