Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory?

It is unlikely that a desire to die emerging as a symptom of psychiatric illness would do so without significantly impairing the patient's decision-making capacity.

“Firstly, that while a desire to die can certainly emerge as a symptom of psychiatric illness, it is unlikely -if not implausible -that it would do so without significantly impairing the patient's decision-making capacity [10].”

• cites [10] Vandenberghe J . Euthanasia in Patients with Intolerable Suffering Due to an Irremediable Psychiatric Illness: A Psychiatric Perspective. In: Jones DA , Gastmans C , MacKellar C , eds. Euthanasia and assisted suicide: lessons from Belgium. Cambridge: Cambridge University Press, 2017: 150–72. sourceNot checked yet

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• AssumptionRests on an assumption: A desire to die can emerge as a symptom of psychiatric illness.

The greater caution needed when assessing PAS requests from psychiatric patients does not require their outright exclusion.

“Secondly, that although this factor certainly necessitates greater caution in the assessment of requests for PAS from psychiatric patients compared to those with somatic conditions, it does not necessitate the outright exclusion of psychiatric patients.”

• AssumptionRests on an assumption: A desire to die can emerge as a symptom of psychiatric illness.

Failing to assess patients individually, and treating them instead as members of a social group, would be unjustifiable discrimination.

“To do otherwise would be an instance of unjustifiable discrimination against the members of the particular social group in question.”

Feelings of hopelessness have been shown to have a crucial relation to feelings of unbearable suffering in people experiencing both mental and physical illnesses.

“For feelings of hopelessness have been shown to have a crucial relation to feelings of unbearable suffering for those experiencing both mental and physical illnesses [15].”

• cites [15] Solano, 2016, Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients, BMC Palliat Care sourceNot checked yet

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It is possible for a person to be both depressed and competent.

“Kissane and Kelly, for example, note that “the transition phase through which competence is sustained before a depressed patient loses their previously-held positive world view is unclear,” suggesting that it is possible for someone to be both depressed and competent [2].”

• cites [2] sourceNot checked yet

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Hopelessness is introduced into both psychiatric and somatic treatment by the institutionalisation of PAS.

“Hopelessness, therefore, is introduced into both psychiatric and somatic treatment by the institutionalisation of PAS.”

The relative uncertainty of psychiatric diagnoses and prognoses compared with somatic conditions does not require excluding psychiatric patients from assisted dying.

“The relative uncertainty of psychiatric diagnoses and prognoses compared to those relating to somatic conditions, then, does not necessitate the exclusion of psychiatric patients from access to assistance in dying.”

There is good reason to believe that current Dutch assessment practice provides insufficient safeguards for persons as vulnerable as those with psychiatric illness.

“Now, there is certainly good reason to believe that this current practice provides insufficient safeguards for persons as vulnerable as those experiencing psychiatric illness.”

Even when patients have not responded to a wide variety of treatments over an extended period, there remains hope that they will eventually improve.

“But even if patients are non-responsive to a wide variety of treatments for an extended period of time, there is still hope that they will eventually improve.”

• cites [11] Blikshavn, 2017, Four reasons why assisted dying should not be offered for depression, J Bioeth Inq sourceNot checked yet

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Assuming PAS is permissible for patients with somatic conditions, none of the three arguments examined is strong enough to demonstrate that excluding psychiatric patients from access to PAS is justifiable.

“I argue that, if we accept that PAS is permissible for patients with somatic conditions, then none of these three arguments are strong enough to demonstrate that the exclusion of psychiatric patients from access to PAS is justifiable.”

• Also stated in: § 5. Conclusion · plain

  “If we accept that PAS is permissible for patients with somatic conditions, I have argued that none of these three arguments are strong enough to justify the exclusion of psychiatric patients from access to PAS.”

• AssumptionThe authors state this as an assumption: PAS is morally permissible for patients suffering from terminal, somatic conditions.

Psychiatric diagnostic categories necessarily include patients with widely differing aetiology and maintenance factors underlying the current symptoms and behaviour.

“Consequently, “diagnostic categories are bound to include patients with vastly different aetiology and maintenance factors that underlie the current symptoms and behaviour,” [11]”

• cites [11] Blikshavn, 2017, Four reasons why assisted dying should not be offered for depression, J Bioeth Inq sourceNot checked yet

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There is currently no evidence that standards of care or the rate of progress of medical research into psychiatric treatments have suffered in Belgium and the Netherlands as a result of permitting psychiatric PAS.

“Yet there is currently no evidence to suggest that standards of care or the rate of progress of medical research into psychiatric treatments has suffered as a result.”

Physicians have a duty to assess the competence of each patient individually, regardless of the nature of the patient's illness.

“Given this, insofar as physicians have a duty to assess and treat patients as individuals as opposed to members of statistically circumscribed groups, they have a duty to assess the competency of each patient individually, regardless of the nature of their illness.”

In the MacArthur Treatment Competence Study, patients with mental illness as a group showed more deficits in understanding, appreciation and reasoning than medically ill patients and non-ill controls.

“on the measures of understanding, appreciation, and reasoning, as a group, patients with mental illness more often manifested deficits in performance than did medically ill patients and their non-ill control”

• cites [7] sourceNot checked yet

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Psychiatric patients who request PAS are likely to have long illness histories and prior psychiatric treatment, so that further treatments would appear even less likely to be effective.

“Furthermore, psychiatric patients that request PAS are likely to be those who have suffered from their illness for lengthy periods of time with histories of psychiatric treatment, i where the potential effectiveness of further treatments would appear even slimmer.”

Capacity assessments performed in the Netherlands for psychiatric patients seeking assistance in dying have been limited to global assessments rather than more granular, cautious evaluations.

“Capacity assessments performed in the Netherlands for psychiatric patients seeking assistance in dying, for instance, have been limited to global assessments of decision-making capacity, as opposed to more granular, cautious evaluations [9].”

• cites [9] SYH, 2016, Should assisted dying for psychiatric disorders be legalized in Canada?, Can Med Assoc J sourceNot checked yet

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Mental illness by itself is insufficient to establish that a patient is incompetent.

“Studies that have been conducted into mental illness and decision-making capacity have shown that mental illness is insufficient to demonstrate incompetency [7].”

• cites [7] sourceNot checked yet

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A prediction of a person's psychiatric prognosis can only rest on statistical generalisations, not on the actual causes of the illness in that individual case.

“and any prediction of a person's prognosis can only be based upon statistical generalisations, as opposed to the actual causes underlying the illness in each individual case.”

The objection that institutionalising psychiatric PAS would harm psychiatric care fails to provide a morally justifiable basis for excluding psychiatric patients from assisted dying.

“Objecting to the institutionalisation of psychiatric PAS on this basis, therefore, fails to provide a morally justifiable basis upon which to exclude psychiatric patients from access to assistance in dying.”

Psychopathology does not automatically mean that a patient lacks mental capacity.

“Similarly, Olie and Courtet also note that “[p]sychopathology does not automatically mean that a patient lacks mental capacity” [3].”

• cites [3] Olié, 2016, The controversial issue of euthanasia in patients with psychiatric illness, JAMA sourceNot checked yet

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Physicians are better placed to identify suitable and effective treatments when they can characterise the psychopathological or pathophysiological mechanism causing an illness than when its causes are unknown.

“By being able to characterise the psychopathological or pathophysiological mechanism(s) that are causing an illness, physicians are better placed to identify suitable and effective treatments compared to instances wherein the causes of an illness are unknown.”

Physician-assisted suicide on the basis of psychiatric suffering has been legally permitted in Belgium and the Netherlands since 2002.

“Notable exceptions to this are Belgium and the Netherlands, where PAS on the basis of psychiatric suffering has been permitted since 2002 [1].”

• Also stated in: § 4. The risks of institutionalisation · plain

  “Firstly, as previously noted, PAS for psychiatric conditions has been permitted in Belgium and the Netherlands for 17 years.”

• cites [1] Dyer O , White C , García Rada A . Assisted dying: law and practice around the world. BMJ 2015;351.doi:10.1136/bmj.h4481 sourceNot checked yet

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The Netherlands has the highest research productivity in psychiatry in the world when adjusted for GDP.

“In fact, the Netherlands has the highest research productivity in psychiatry in the world, when adjusted for GDP [14].”

• cites [14] sourceNot checked yet

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Between 2011 and 2014, at least 68% of psychiatric patients who received assistance in dying had psychiatric histories of over 11 years.

“Between 2011 and 2014, at least 68% of psychiatric patients that received assistance in dying had psychiatric histories of over 11 years.”

• cites [12] Elzakkers, 2018, Assessment of mental capacity to consent to treatment in anorexia nervosa: a comparison of clinical judgment and MacCAT-T and consequences for clinical practice, Int J Law Psychiatry sourceNot checked yet

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A diagnosis of even a severe mental illness such as schizophrenia does not preclude a patient from being competent.

“The authors of the MacArthur Treatment Competence Study, for instance, conclude that being diagnosed with even a severe mental illness like schizophrenia does not preclude a patient from being competent [8].”

• cites [8] Hindmarch, 2013, Depression and decision-making capacity for treatment or research: a systematic review, BMC Med Ethics sourceNot checked yet

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The wide aetiological variance within psychiatric diagnoses increases uncertainty both about prognosis and about treatment effectiveness.

“The fact that psychiatric diagnoses frequently include patients with wide aetiological variance not only magnifies the uncertainty of prognoses, but also the uncertainty of treatment effectiveness.”

Mental illness often negatively affects a person's decision-making capacity.

“The main empirical premise upon which this argument is based -i.e. that decision-making capacity is often negatively affected by mental illness -is fairly uncontroversial, as it has been corroborated in a number of empirical studies [5][6][7][8].”

• cites [5] sourceNot checked yet

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• cites [6] sourceNot checked yet

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• cites [7] sourceNot checked yet

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The certainty of relief from suffering through PAS may be preferable to a patient than an indefinite future of continued suffering, even given the possibility of spontaneous recovery years or decades later.

“But again, the certainty of relief from suffering that a patient would receive from PAS may be far preferable to them than an indefinite future of continued suffering, despite the possibility that they may make a spontaneous recovery years or decades down the line.”

Psychiatric patients are at a significant disadvantage in receiving treatment that is both effective and consistent with their own value judgements of appropriateness.

“This puts psychiatric patients at a significant disadvantage in terms of receiving treatment that is both effective and consistent with their own value-judgements of individual appropriateness.”

Denying PAS to a patient with a long-standing, refractory, competently assessed condition would undermine that patient's self-determination against their own best interests.

“Yet rather than acting in the best interests of the patient, denying the request for PAS would undermine the self-determination in spite of the patient's best interests to be relieved of”

The certainty of a refractory psychiatric diagnosis is always open to doubt, because there is always some possibility that the patient will recover.

“The certainty of a refractory diagnosis is thus always open to doubt, as there is always at least a sliver of hope that the patient will recover.”

Because mental illness does not always compromise decision-making capacity, the argument from compromised capacity can at most justify a weaker conclusion that still permits psychiatric PAS in some instances.

“Thus, if it is not true that people with severe psychiatric illnesses have all been rendered incompetent or have had their decision-making capacities compromised by their illness, then the argument is only able to justify a weaker conclusion that still admits the moral permissibility of psychiatric PAS in at least some instances.”

Admitting that certain somatic illnesses are medically futile may make terminally ill individuals vulnerable to experiencing their suffering as unbearable and to seeking assisted dying when they otherwise would not have.

“By admitting that certain instances of cancer, AIDS, heart disease, and so on, are medically futile, we may be making individuals with terminal illnesses vulnerable to experiencing their suffering as unbearable, leading them to seek out medical assistance in dying where they may not otherwise have done so.”

In jurisdictions where PAS is currently permitted for somatic conditions, excluding psychiatric patients on the basis of any of the three arguments examined would constitute unjustifiable discrimination against those with psychiatric conditions.

“One important implication of this would be that, in jurisdictions wherein PAS is currently permitted for those suffering from somatic conditions, the exclusion of psychiatric patients on the basis of any of the three arguments addressed in this paper would constitute an instance of unjustifiable discrimination against those suffering from psychiatric conditions.”

• AssumptionThe authors state this as an assumption: PAS is morally permissible for patients suffering from terminal, somatic conditions.

In relation to the moral permissibility of PAS, the divide between mental and physical illnesses is significantly weaker than is commonly assumed.

“If my arguments are sound, this would suggest that, in relation to the moral permissibility of PAS, the divide between mental and physical illnesses is significantly weaker than is commonly assumed.”