Thoughts on physician aid in dying for SPMI?

[futureapppsy2]

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Curious as to your thoughts on if physician aid in dying (aka physician assisted suicide aka death with dignity) should be legal/ethical for people with SPMI—as a suicide researcher, I started out firmly in the “no” camp but have honestly moved towards the “yes” camp as I’ve moved through my career and gained clinical experience. If someone has a non-terminal chronic illness that has been through adequate treatment trials and their condition either hasn’t responded to tx or their residual symptoms still cause such a degree of suffering as to make death preferable, it seems ethically defensible to let them make the informed choice to die, provided appropriate safeguards are in place (e.g., they make the request independently, they request multiple times, they demonstrate adequate comprehension of what they are requesting), and drawing a line between mental and physical illness seems needlessly dualistic and invalidating of mental suffering as suffering. With mental illness, you do have more complexities around competency, but if you have someone who is in a non-psychotic state and demonstrates clear and accurate understanding of the prognosis of their illness, the finality of death, and their available options, I don’t see why they would be inherently unable to make an informed decision about their life.

Thoughts?

 

[calvnandhobbs68]

It's not like I have a ton of ethical knowledge about this or anything, but I'd feel that with allowing assisted death for SPMI it would have to go one way or the other...how could you possibly hold anyone liable then for suicide as a "bad outcome" from a malpractice standpoint if you're going to say that it's ethically defensible in cases of severe mental illness as well? I personally think suicide should never be the issue of a malpractice case anyway, so that would be great from my standpoint but I wonder how that would duel with the idea we have now where we often try to prevent suicide at all costs (like psychiatrists getting called for "SI" for people with terminal cancer for instance....I've been in those consults).

 

[futureapppsy2]

It's not like I have a ton of ethical knowledge about this or anything, but I'd feel that with allowing assisted death for SPMI it would have to go one way or the other...how could you possibly hold anyone liable then for suicide as a "bad outcome" from a malpractice standpoint if you're going to say that it's ethically defensible in cases of severe mental illness as well? I personally think suicide should never be the issue of a malpractice case anyway, so that would be great from my standpoint but I wonder how that would duel with the idea we have now where we often try to prevent suicide at all costs (like psychiatrists getting called for "SI" for people with terminal cancer for instance....I've been in those consults).

One argument I've seen for PAID across the board (terminal illness, non-terminal physical chronic illness, SPMI, etc), is that it has the potential to reduce suicide by giving people a way out if they truly desire that over an extended period of time, versus transient or reactionary suicidality (say, s/p a breakup or job loss or even a new-onset, not-yet-treated condition). So, in these models, the general idea would be that suicide prevention would still be practiced, but if a patient still truly would prefer death after trialing treatments and shows clear understand of their options, then they could pursue PAID. There's also the idea, supported by some (albeit limited) research, that access to PAID itself reduces suicidality, because people know its an option if things truly become unbearable.

 

[wolfvgang22]

I have thoughts but I don't feel comfortable sharing them due to the controversial nature of the topic. It's possibly...👓 ...career suicide.

 

[futureapppsy2]

I have thoughts but I don't feel comfortable sharing them due to the controversial nature of the topic. It's possibly...👓 ...career suicide.

Honestly, I've been surprised how varied opinions on PAID (for both terminal and non-terminal conditions) have been in professional and activist circles. Even in the disability activist community, which is usually seen as very anti-PAID, I've seen well-known people express a range of opinions on it--same in psychology.

(Also, that show was epically, hilariously bad and is thus a national treasure! 😉 )

 

[K9friend]

I'm a pharmacist, not a psychiatrist, but I am totally against this. I wanted to offer my perspective as a patient. I have bipolar disorder and a psychotic disorder. My twenties were spent feeling chronically suicidal with poorly controlled mood symptoms and delusions. I was on disability and lived in complete squalor. I would have been happy to avail myself of the option for physician assisted suicide if it had been available, and I likely would have been deemed competent to make the decision because my suicidal ideation was chronic rather then acute.

However, years of therapy, medication, and most especially meaningful work led to tremendous healing. Today, I am still in therapy and on meds, but I am off disability and no longer suicidal. People can get much better if they are given a long enough chance - but it can definitely take a very long time. I am so glad physician assisted suicide was not an option for me because then I never would had a chance to see the beauty in life or realize my full potential.

And what about conditions like borderline personality disorder that tend to improve with age? Chronic suicidal ideation is common in these patients' young adult years, but can get much better if they don't die before they have the chance to improve.

Assisted suicide for terminal physical illness is a whole different can of worms, but in my opinion assisted suicide for mental illness is totally antithetical to a recovery model.

 

[Psychresy]

I'm a pharmacist, not a psychiatrist, but I am totally against this. I wanted to offer my perspective as a patient. I have bipolar disorder and a psychotic disorder. My twenties were spent feeling chronically suicidal with poorly controlled mood symptoms and delusions. I was on disability and lived in complete squalor. I would have been happy to avail myself of the option for physician assisted suicide if it had been available, and I likely would have been deemed competent to make the decision because my suicidal ideation was chronic rather then acute.

However, years of therapy, medication, and most especially meaningful work led to tremendous healing. Today, I am still in therapy and on meds, but I am off disability and no longer suicidal. People can get much better if they are given a long enough chance - but it can definitely take a very long time. I am so glad physician assisted suicide was not an option for me because then I never would had a chance to see the beauty in life or realize my full potential.

And what about conditions like borderline personality disorder that tend to improve with age? Chronic suicidal ideation is common in these patients' young adult years, but can get much better if they don't die before they have the chance to improve.

Assisted suicide for terminal physical illness is a whole different can of worms, but in my opinion assisted suicide for mental illness is totally antithetical to a recovery model.

But what about for the patients where there is no viable recovery? I think for whatever the reason when we/people think about mental illness there's almost this presumption that we should get them better because it's "just" mental illness. But in reality there's a large swath of patients, no different from a terminal cancer patient, who are simply going to live in misery until they succumb to the sequelae of their illness. I think in these cases assisted suicide should be an option after all else has been exhausted.

 

[K9friend]

But what about for the patients where there is no viable recovery? I think for whatever the reason when we/people think about mental illness there's almost this presumption that we should get them better because it's "just" mental illness. But in reality there's a large swath of patients, no different from a terminal cancer patient, who are simply going to live in misery until they succumb to the sequelae of their illness. I think in these cases assisted suicide should be an option after all else has been exhausted.

I guess my thought on that is that it's hard to say that there is no viable recovery. There might not be great treatment options now, but what about in 5 or 10 years? Also, I think sometimes people overlook just how long it can take for an effective treatment to work. You might not see an effect in a month or even a year, but with enough time in effective treatment, I do think many people's situations can significantly improve. My issue is not so much with suicide itself because some patients will die by suicide no matter how hard you try. My issue is the idea of a physician saying that the best we can offer you is an early death. It seems too bleak and hopeless. With ALS or Lewy Body Dementia it's different, but with mental illness I think it does patients a disservice to lose hope. I don't mean that as a criticism of you, so please don't take it that way because I can tell from your post that you come from a position of caring about the patient's best interest.

 

[Old&InTheWay]

I see this in a similar light to the idea of having a safe drug supply. People can and do find ways to effectively kill themselves if they want to die regardless of whether a humane method is available. Why should people be left brain injured and in pain after a failed serious suicide attempt (by hanging, GSW)? I almost always come down on the side of autonomy and I don't see why people should not be able to make the decision to stop living.

That said, I believe that most suicide attempts are not done from sincere wishes to die, but rather to escape distress and communicate their pain. I do not think most of these folks would seek out PAID and for those who do, perhaps the experience of talking about this choice would be therapeutic. I wonder whether some good work could be done with people (particularly those with BPD) if we could have frank discussions with the option of suicide actually being on the table as a choice for the patient to consider. I think it might highlight the will of the patient and a choice to engage in treatment could be more meaningful.

Or maybe it would be terrible. I don't know. But I also don't think that my personal feelings about it should get in way of other people's self-determination. And in a similar vein, no physician should be compelled to participate if it feels wrong to them.

 

[futureapppsy2]

That said, I believe that most suicide attempts are not done from sincere wishes to die, but rather to escape distress and communicate their pain. I do not think most of these folks would seek out PAID and for those who do, perhaps the experience of talking about this choice would be therapeutic. I wonder whether some good work could be done with people (particularly those with BPD) if we could have frank discussions with the option of suicide actually being on the table as a choice for the patient to consider. I think it might highlight the will of the patient and a choice to engage in treatment could be more meaningful.

That is one of the arguments for PAID, even with terminal illness, actually—that having the option to die if/when things start to become intolerable allows people to enjoy and engage with their life more. A friend’s mother chose PAID for metastatic breast cancer, and my friend truly believed that PAID increased both the length and quality of her life.

Obviously no one with any condition, mental or physical, terminal or not, should be forced or even pressured to choose PAID, but the longer I’m in this field, especially working with folks with severe chronic conditions, the more I see the flaws in forcing people to suffer a life they find intolerable and that we can’t successfully help them make tolerable just because. The vast, vast majority of people with chronic illness, including SPMI, do find meaning and joy in their lives and ways to make a life worth living (whatever that looks like for them), but if someone has truly tried and engaged in treatment and other interventions for years and still suffers to degree that death is truly and persistently preferable to life, I don’t know that giving them the option of a “good death” is a bad thing.

 

[Candidate2017]

My opinion is doctors should stay out of the business of killing patients. At least for physically healthy patients who are physically capable of carrying out their desire to live or die. If someone really wants to kill themselves painlessly, there are plenty of effective means that aren't a secret.

 

[Bartelby]

I'm not convinced completing suicide in a painless, foolproof way on one's own is so easy. Far too many people have found out the hard way that it isn't.

Mental illness is different because:

-suicidality and impaired decision making are often features of these disorders.
-many who survive suicide attempts or otherwise recover from severe episodes are glad to be alive, even if they genuinely wanted death at the time.
-mental illnesses are not typically "hopeless" or terminal in the same sense that, for example, widely metastatic cancer is.

With that said, we don't have tools that will lead to recovery or good symptom control for everyone. I think PAID may be reasonable for SMI if certain criteria are met with regard to demonstrated severe, persistent and untreatable (or minimally treatable) conditions. I suspect these evaluations would be best left for independent forensic examiners who choose to take this on rather than for treating clinicians. I also wonder if knowing it would be an option after demonstrating sufficient engagement with treatment options might result in a good number of people getting treated and feeling their autonomy has been respected as above, potentially decreasing the sense of desperate need to attempt suicide on their own.

 

[futureapppsy2]

I'm not convinced completing suicide in a painless, foolproof way on one's own is so easy. Far too many people have found out the hard way that it isn't.

Mental illness is different because:

-suicidality and impaired decision making are often features of these disorders.
-many who survive suicide attempts or otherwise recover from severe episodes are glad to be alive, even if they genuinely wanted death at the time.
-mental illnesses are not typically "hopeless" or terminal in the same sense that, for example, widely metastatic cancer is.

With that said, we don't have tools that will lead to recovery or good symptom control for everyone. I think PAID may be reasonable for SMI if certain criteria are met with regard to demonstrated severe, persistent and untreatable (or minimally treatable) conditions. I suspect these evaluations would be best left for independent forensic examiners who choose to take this on rather than for treating clinicians. I also wonder if knowing it would be an option after demonstrating sufficient engagement with treatment options might result in a good number of people getting treated and feeling their autonomy has been respected as above, potentially decreasing the sense of desperate need to attempt suicide on their own.

I could also see PAID as harm reduction for family members, as it could remove or significantly reduce the trauma of finding a loved one’s body after a suicide attempt or suicide death.

 

[comp1]

I concur with the above poster where we don't work in a specialty that has conditions where we can know there is no viable recovery. There are cases of terminal borderline personality disorder or terminal depression, but we can only know this after the fact. Our literature is extremely clear on this. Psychiatric conditions do not have predictable courses and recovery is infinitely more likely with our conditions than something like ALS or many metastatic cancers. I think we need to have a lot more knowledge about what exactly we are treating before we consider this road. Treating the mind and body differently is not because they necessarily have some sort of innate difference, but instead reflects our field's dramatic lack of understanding in comparison to others.