Role of Psychiatrists in Assisted Dying: A Changing Trend

Recently, the Governor of California signed a bill with an unusual personal message, supporting a legislature on “dying with dignity” (October, 2015). According to a spokesperson of the American Medical Association, physician-assisted suicide “is fundamentally incompatible with the physician’s role as a healer, would be difficult or impossible to control, and would pose serious societal risk” (1). Psychiatrists have a relatively conservative view on euthanasia (2), rooted in their professional role in treating mental illness that contributes to suicide (3).

Perhaps what is prolonging the debate about the legalization of physician-assisted death is the current conceptualization of what constitutes a “good” or “appropriate” death (4). This includes resolution of internal conflicts, sustenance of one’s personal sense of identity, and reduction of fear of loss of control. However, there is no reliable and effective guiding principle to achieve all these ideals in the care of a dying person.

Definitions of Physician-Assisted Death vs. Euthanasia

For decades, Dr. Jack Kevorkian, a Michigan pathologist was considered the pioneer of the American “assisted suicide” movement. He practiced voluntary euthanasia and assisted 130 people to die between 1980 and 1998, for which he was convicted of murder in the second degree in 1999.

The term “physician-assisted suicide or death” refers to a physician prescribing a lethal dose of a medication, assisting in voluntary death of a patient, without taking part in the administration of the medication (1). This practice is legal in some U.S. jurisdictions, Switzerland, Belgium, the Netherlands, and Luxembourg. On the other hand, in euthanasia, a physician can both prescribe and administer a lethal medication. The practice is legal in Belgium, the Netherlands, and Luxembourg (1). In the present article, the term “physician-assisted death” is used for the purpose of discussion.

Legal Status in the United States and Canada

In 1997, Oregon was the first state to implement the Death with Dignity Act. This allows a physician to prescribe a lethal dose of medication to a patient with appropriate capacity, with an irreparable health problem, and with a life expectancy of less than 6 months. Two different physicians evaluate the patient independently, and on each occasion the patient must communicate his or her informed consent. The evaluations should occur at least 15 days apart in order to ensure time to reconsider the decision. To verify an informed consent, a referral for psychological evaluation must be made when mental capacity is doubtful or influence of mental disorders is suspected. The patient must be informed of all risks, benefits, and alternatives, including palliative options. Ultimately, a patient can always opt to forego lethal medications once prescribed. The timing and context of using the medication is the patient’s choice without any direct involvement by the physician (5).

Just as the Death with Dignity Act awards a multitude of rights to the patients, it similarly leaves room for choice on the part of the physician. If the physician is not willing to participate in this process, a referral can be made to another physician who is willing to do so (5). The states of Washington and Vermont introduced similar laws in 2008 and 2013, respectively.

Inspired by Brittany Maynard’s voluntary assisted death at age 29, the Governor of California signed the End of Life Options Act in 2015. In Montana, assisted death is protected through court ruling. At least 10 additional states currently have a similar bill at different stages of legislative process. In February 2015, the Supreme Court of Canada unanimously voted to lift the 1993 ban on physician-assisted death (6).

Use of Death with Dignity Act and its Impact on Safeguards

While public support for assisted death is accelerating, the medical community has voiced concerns, the most common of which are summarized in Table 1 .

A 2014 Oregon report (7) showed that 24% of people who received lethal prescriptions died of other causes. The median age of people who used the prescription was 72 years. The two most common diagnoses were cancer and amyotrophic lateral sclerosis. The report showed some data both in support of and in opposition to the concerns summarized in Table 1 . There is concern that nonpsychiatric physicians may not be equipped to detect subtle psychopathology and its effect on end-of-life decisions. In the last 10 years, the percentage of psychological referrals has been in the range of 0%–4%, including no referrals in 2007 and 2009 (7). In 2014, only 2.9% of the patients were referred for psychological evaluation before they received the prescription, compared with a cumulative 5.9% psychological referral rate between 1998 and 2013 (8). The other concern within the medical community is that more patients might be triaged to hospice, and patients without sufficient mental capacity would be assisted in death in the interest of conserving health care dollars (9). On the contrary, safeguards exist that mandate physicians to refer patients who may have a mental condition that affects decisional capacity for psychiatric evaluation (10). In two studies, family members of those who had accepted medication for physician-assisted death felt more accepting and prepared for the death when it actually occurred (11, 12).

In response to the persistent discomfort of the medical community, some authors (13) proposed a state or federal drug prescription system, obviating the treating physicians’ active participation in the process. However, removing a treating physician from the final decision would affect the continuity of care at the end of life, especially when a dynamic discussion about ongoing and available options is necessary.

Role of Psychiatrists

In discussing the “safeguards,” some have advocated a mandatory psychiatric evaluation of competence in each patient requesting physician-assisted death, which would essentially use the psychiatrist as a “gatekeeper” (14). While psychiatry has a great deal to offer in capacity evaluation, competence is a complex socio-legal construct, which cannot be assessed using the standardized instruments of capacity evaluation. Often, a sliding scale or risk-sensitive model is used clinically to evaluate the decision-making capacity, whereas competence is judged by legal standards. Capacity evaluation finds a viable compromise between the conflicting values of autonomy and beneficence, but empowers the experts to make an “ad hoc” decision using their own moral values as a reasonable standard. In a survey, psychiatrists’ moral beliefs correlated with whether they were in support of physician-assisted death (15). Capacity assessments are influenced by physicians’ subjective experiences, often not encompassing the social and noncognitive aspects implicated in a patient’s decision making.

Historically, suicide was viewed as a threat to the social fabric and a punishable offense, and the moral/religious model considered it a violation of core human values (14). With evolution, the psychiatric model considered suicide as a product of treatable mental illness and not a choice of a rational mind. The view that suicide is a symptom of treatable mental illness is at odds with the view that some suicides among terminally ill patients are rational choices in response to illness that cannot be treated.

Like the rationality of some suicides, the refractoriness of a mental disorder is also a matter of debate. In the Netherlands, the law of assisted death and euthanasia can be used in refractory mental disorders, following proper consultation and review committee agreement. A recent study on a Dutch database showed that in 24% of cases of untreatable mental disorders in which euthanasia or assisted death was used, there were disagreements among the consultants regarding what constituted unbearable suffering and futility of further treatment (16). As the prognosis of mental disorders is variable, we do not yet have the tools to determine the threshold for psychiatrists to consider the option of assisted death. Refractory mental disorders, in the absence of a terminal medical illness, are not legally approved for physician-assisted death in the United States at this time. However, that this one day could become the case invites a broader discussion about societal, moral, and ethical implications.

Conclusions

As the momentum builds for autonomy at the end of life, concerns over adequacy of mental capacity in such cases abound. Psychiatric consultation is imperative to determine whether a patient’s psychopathology, however covert, is influencing his or her judgment. More systematic studies are needed to inform the development of psychiatric evaluations that assess capacity in these complex situations. Since physician-assisted death is becoming more widely accepted, its legal status, as well as ethical issues surrounding end-of-life care, should be formally taught in medical schools and psychiatry residencies.

Key Points/Clinical Pearls