Assisted Suicide for Mental Illness Talk Notes

These notes are from a talk entitled “Assisted Suicide for Mental Illness” that was given by Dr. Mark S. Komrad as a part of the DC Profs and Pints talk series.

PAS = Physician Assisted Suicide

• Does the existence of PAS serve as a barrier for meaningful engagement with interventions/options before PAS?
  • Evidence seems to suggest that most people don’t even try behavioral talk therapy
  • Even if people are required to exhaust options would they only half engage?
• I don’t think that psychiatrists should be allowed to preemptively suggest PAS to their patients because of the trust afforded to professionals.
  • See halo effect + cueing effect
• Does PAS as an option make doctors more likely to give up on their patients?
  • Can having a safety hatch exit plan reduce the determination of a doctor?
  • Are overwhelmed doctors incentivized to recommend PAS as an option to their more demanding patients?
• “Verbicide” the sheer number of terms around PAS that differ from country to country and organizations that are trying to push their agenda
  • Most are trying to sidestep the value-laden term of suicide which is potentially bad because then it because more easily normalized from the sanitized version
• PAS is a self-administered prescription whereas Euthanasia is administered by someone else (usually a medical professional)
• There seems to be conflicting roles/duties for doctors to prevent vs provide suicide in patients.
• Where does the line between a preventable and prescribable suicide lie?
• PAS is usually only considered for Unbearable and Untreatable conditions
• Most people choose Euthanasia over PAS
  • Euthanasia is usually quicker and more painless
  • I imagine outsourcing the locus of control is also emotionally helpful
• Suicide is no longer illegal in the U.S. so does it make sense to provide the means to people?
  • Does institutionalizing suicide prevent undue suffering?
• In countries where PAS is already legal, why are we seeing an increase?
  • Have the times gotten worse post-COVID?
  • Is there a acculturation/normalization effect in place that makes people more likely to seek PAS out as an option?
• If a physician who can decide whether or not to allow euthanasia is also the one carrying it out is that not a conflict of interest?
  • Sometimes a physician might refer you to someone else, but how much can that person know about your condition and whether or not your case is irremediable? How does being distant vs close to the situation/person affect decision-making?
• Are people with mental illness/terminal illness sufficiently competent? Should we allow people with the power of medical decision-making make a decision for their terminally ill person?
• What is a personality disorder? Why are they requesting PAS at such a high rate compared to other mental disorders?
  • Why do up to 1/3 not have a history of therapy? Are they refusing treatment?
  • Why is BPD the highest represented personality disorder? Is it the most diagnosed?
• If we allow people to refuse treatment (as we probably rightly should), how can we ensure that people have exhausted previous options before PAS?
• Is disallowing people with intellectual disabilities to not get PAS ableist?
  • Should we allow caretakers to consider PAS for them? That surely seems like a conflict of interest.
  • How deeply does someone need to understand that they want to die before they are allowed to? Can anyone ever fully be aware of the consequences of their choices?
• Should we allow elders to have access to PAS without medical reasons, just old age?
  • Does the predictability of death by PAS allow better family planning, knowledge transfer, and a better grieving process?
• I think that PAS is a “cursed problem” where there is a paradox between goals that means that only trade-offs can be made.
  • Trade-offs can only be made from values (ethics)
• Is there a conflict of interest/ethical problem from allowing PAS patients to donate organs?
  • Is this “virtue coercion”?
  • Does an honorable death give some people motive?
• Should there be age limits on PAS?
• Should people be allowed to issue advanced directives like if X happens to me they should euthanize me?
  • People can change their mind
  • People might not have the consciousness to assess if their mind has changed
• People often point to the rise in representation in PAS in the total death count/as a large category of death in a country, but I don’t think that really matters that much.
  • We are hopefully reducing death in other areas so it makes sense that voluntary death would increase.
• In Belgium the PAS rate went down after requiring therapy but then went back up again – what does this mean?
• Do we have a demonstrated slippery slope for the relaxation of conditions for PAS?
• Should prisoners be able to request euthanasia?
  • In what ways is this a different moral problem than the death penalty?
  • Should we enforce punishment of the soul by keeping them alive in prison with no future prospects?
• Governments with nationalized health care as well as insurance companies in countries where the system isn’t seem to have motive for PAS
  • It is cheaper than expensive treatment
  • It reduces population/demand for treatment within the system
  • Could the state/system mandate PAS for certain conditions/thresholds?
• Governments also have incentive for PAS because of suicide tourism and incentive to keep conditions relaxed as well
• Terminal condition vs reasonably foreseeable death (Canada)
  • No explicit provisions for mental health but is usually deemed too difficult to predict reasonably foreseeable death
  • Does suicidal ideation count as reasonably foreseeable death?
• Is PAS rate a signal about the state of a country’s medical care system? Are not serving the people?
• How long should the waiting periods be for reasonably foreseeable vs non-reasonably foreseeable death?
• If there is no peer reviewed evidence for the reliable identification of irremediability in mental illness cases why are we allowing doctors to make those calls themselves?
• How does doctors/psychiatrists feel about PAS?
• In Canada the decisions about PAS keep on getting booted down the line because decisions can’t be reliably made from evidence
• How is PAS applied across class, race, gender, etc.?
  • It seems that PAS replaces other social welfare programs, PAS can be an option when medical bills or even just therapy can’t be afforded
• Should familial notification be required?
  • At the very least should someone else be required to sign-off? It seems like someone with their best interests in mind isn’t ever consulted in the process, just between the doctor and patient.
• I think there are probably mental health cases of things like treatment resistant depression that warrant PAS, but I think that it is impossible to create a reliable system.
• How is it moral to allow PAS if the government is doing so little to address the conditions that would bring someone to consider PAS?
• I doubt the government’s ability to do its best by patients pursuing PAS.
• I think that it would be better for governments to not allow PAS because that is overall less government intervention than institutionalizing it. The alternative would be to just allow it but that seems like it would be less safe for the public.
• Should evaluations by telemedicine be allowed for PAS?
  • Telemedicine aside, how many sessions should be required in order to prescribe euthanasia?
• Doctors in Oregon are not referring to psych for evaluations but why?
• There are not state residency requirements for states in the U.S. that allow/offer PAS, so it is de facto available in the U.S.
• What is the monetary costs to insurance and/or patient for PAS?
• Is PAS a “less restrictive alternative” to forced hospitalization as some courts have explored?
• Should doctors be allowed to not refer/prescribe euthanasia even if it is legal?
• Does PAS lead to suicide contagion?
• The American Medication Association (AMA) does not allow PAS, and the American Psychological Association (APA) follows the resolution
• Futility of care, personal autonomy, and reduction of suffering are the ethical arguments for PAS
  • PAS is pseudo-autonomy because at the end of the day the person still needs doctor approval
  • Futility is inscrutable in medicine, especially in mental illness
• Unassisted suicide rates are up in Oregon
  • Could it be some people take their life as a result of not being approved for PAS and so there is capture from what would be an assisted suicide into the unassisted suicide category?
• PAS removes the inconvenience associated with suicide/some of the interpersonal consequences which sometimes steer people away from suicide
• How does PAS affect doctors?
  • A lot of them are traumatized from it
• Should religious institutions be allowed to opt-out from administering euthanasia?
• PAS policies implicitly make statements about what lives are worth living
• Does PAS allow the fetishization of death from potential seekers?
• How do ethical cases for PAS differ from that of abortion?