Assisted dying on the basis of suffering

Transcription

1 Assisted dying on the basis of suffering concerns, from mental illness Legitimate specious arguments Mind, Medicine & Morals the ethics of psychiatry and mental health care, Graduate papers session, July 5, 2018 Martina A. Hodel, PhD candidate, Institute of Biomedical Ethics and History of Medicine University of Zurich

2 Scope/hypothesis The objections to psychiatric Euthanasia/assisted dying (EAD) do not stand up to close scrutiny because The normative criteria for EAD are either too vague Or they are equally applicable to physical illness

3 Why a right to die? Hendry et al., 2013 Concerns about poor quality of life Unbearable suffering, dependency, burden Desire for good quality of death Choice, autonomy, control

4 Assisted dying + psychiatry EAD on the basis of a primary psychiatric disorder possible in Switzerland, The Netherlands, Belgium, Luxembourg Recent data from The Netherlands and Belgium has elicited strong response

5 Death with Dignity Act (OR) Due care criteria (NL) Adult (age 18 or older), Oregon resident Capable Diagnosed with a terminal illness (incurable and irreversible) that will lead to death within six months Voluntary and well considered request (decisional competence) Unbearable suffering without prospect of improvement (Informing the patient about situation and prognosis) No reasonable/acceptable alternative Based on a shared decisionmaking process

6 Terminal illness criterion Safeguard Terminal illness criterion is an artificial restriction No terminally ill clinical diagnosis Not in line with the fundamental principle on which EAD has evolved: Discrimination of non-terminally ill patients

7 No prospect of improvement Objection: Not meaningfully applicable to mental illness Prognostic uncertainty high, spontaneous remission No reasonable alternative: What can be expected? Demoralization > Self-fulfilling prophecy

8 Source of suffering Source of suffering decisive: Less reluctant in accepting EAD requests based on physical pain Study of 911 cases in Oregon Blake et al., 2013 loss of autonomy 92% unable to participate in enjoyable activities 90% loss of dignity 79% inadequate pain control 25%

9 Decision-making capacity e.g. Okai et al., 2007 Objection: Decision-making capacity (DMC) likely impaired and difficult to assess in mental illness However: A majority of psychiatric patients has DMC Prevalence of impaired DMC in the terminally ill?

10 Specious arguments Normative concepts ill defined or too vague to reasonably include or exclude patient groups Or equally applicable to somatic illness Source of suffering: psychosocial/psychological DMC in terminally ill patients?

11 legitimate concerns No sophisticated prospective evaluation systems No Gold Standard in evaluating treatmentresistance and DMC No systematic monitoring Limited resources (especially for mental health care) What about countries without universal health care coverage?

12 Conclusion Hiding behind ideological lens of opposition is harmful Transparence: Risk of false positive too high > burden of medical failure has to be carried by patients Due care: Significant resources needed: Consequence?

13 Selected references Appelbaum, P. S. (2016). Physician-assisted death for patients with mental disorders reasons for concern. JAMA psychiatry, 73(4), Blanke, C., LeBlanc, M., Hershman, D., Ellis, L., & Meyskens, F. (2017). Characterizing 18 years of the death with dignity act in Oregon. JAMA oncology, 3(10), Blikshavn, T., Husum, T. L., & Magelssen, M. (2017). Four reasons why assisted dying should not be offered for depression. Journal of bioethical inquiry, 14(1), Dierickx, S., Deliens, L., Cohen, J., & Chambaere, K. (2016). Euthanasia in Belgium: trends in reported cases between 2003 and Canadian Medical Association Journal, cmaj Hendry, M., Pasterfield, D., Lewis, R., Carter, B., Hodgson, D., & Wilkinson, C. (2013). Why do we want the right to die? A systematic review of the literature on the views of patients, carers and the public on assisted dying. Palliative Medicine, 27(1), Kim, S. Y., De Vries, R. G., & Peteet, J. R. (2016). Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to JAMA psychiatry, 73(4), Kim, S. Y., & Lemmens, T. (2016). Should assisted dying for psychiatric disorders be legalized in Canada?. Canadian Medical Association Journal, 188(14), E337-E339 Okai, D., Owen, G., McGuire, H., Singh, S., Churchill, R., & Hotopf, M. (2007). Mental capacity in psychiatric patients: systematic review. The British Journal of Psychiatry, 191(4), Schuklenk, U., & van de Vathorst, S. (2015). Treatment-resistant major depressive disorder and assisted dying. Journal of medical ethics, 41(8), Vandenberghe, J. (2018). Physician-assisted Suicide and Psychiatric Illness. New England Journal of Medicine, 378(10),

14 Slippery slope argument Ethically acceptable practice: voluntary euthanasia 1. Slope is slippery 2. Ending up at the bottom is undesirable Ethically objectionable practice: nonvoluntary euthanasia