Tuesday, June 11, 2019

The Euthanasia Debate

For your edification, here are some interesting thoughts about euthanasia from a Dutch psychiatrist. We examined the issue last week in reporting the death of Noa Pothoven, a Dutch teenager who chose to let herself die by refusing food and water.

As noted in my previous post, medical authorities did not euthanize Pothoven; they sat by, with her parents, while she let herself die. Whether that is more or less appalling than putting a teenager to death, I will let you decide. At the least, it was completely unacceptable.

For now, we examine the thoughts of Dutch psychiatrist, Damiaan Denys, as printed in the American Journal of Psychiatry in 2018. (via Maggie’s Farm) He begins with a brief discussion of a case he had worked on. A 42 year old woman suffering from depression wanted to be euthanized. Denys and his team had worked with her and had reduced some of her symptoms. When she asked to be euthanized they rejected her request. She then asked her primary care physician to allow her to die, and he agreed. They could do nothing to stop it.

It’s one thing to prescribe euthanisia for a terminally ill cancer patient. It’s quite another to prescribe it as a “treatment” for depression.

Denys explains:

Arguments pro euthanasia contend that it would be unfair to exclude psychiatric patients if they fulfill the due care criteria, that psychiatric suffering might be worse than somatic suffering, that euthanasia offers a dignified medical alternative to patients who otherwise might complete suicide, and that considering a request for assistance in suicide is part of the responsibility of a psychiatrist.

Arguments contra euthanasia maintain that the criteria for psychiatric suffering are less objective than somatic suffering, that psychiatric disorders per se are not life threatening, that the distinction between disorder-related and suffering-related desire to die is hard to establish, that there is a serious risk that the psychiatrist’s granting of a request is contaminated by countertransference, that the extent to which a request from an acutely ill psychiatric patient can be voluntary and well considered is doubtful, and that there is a question of whether one should consider granting a request for assisted death when the quality of mental health care is not sufficient.

The phrasing is interesting. Proponents of euthanasia believe that mental suffering “might be worse” than physical pain. How do they know this? And they also consider euthanasia to be a “dignified medical alternative” to suicide. Why do they imagine that these are the only alternatives?

Fair enough, the patient Denys had been treating for depression had experienced some, but not complete symptom amelioration. But, shouldn’t that be a sign that treatment might benefit her, not a sign that treatment had failed her. Considering that depressed patients tend to see the glass half empty, why would you allow them to act on their opinion that there was no hope?

In the Netherlands psychiatrists cannot overrule a primary care physician who prescribes euthanasia, More importantly, psychiatry has as its goal reducing suicidal ideas and behaviors. But, doesn’t euthanasia, when granted to a psychiatric patient tell a different story… namely that the case is hopeless. If a physician believes that the case is hopeless, won’t the patient naturally conclude that he or she do nothing to improve her condition:

How can we reconcile the daily practice of reducing suicidal ideas and behaviors in patients with respecting a death wish in single cases? How can we distinguish between symptoms and existential needs? How can we decide whether a psychiatrist is sufficiently autonomous to judge euthanasia? Does the fragile therapeutic relationship between psychiatrist and patient not bias judgment? How are differences in opinion between psychiatrist and patient resolved? Although psychiatrists are not legally obliged to approve or execute euthanasia, neither can they interfere once a request is granted by a third party, as illustrated in the aforementioned case.

Moreover, if a patient can simply seek out another medical professional and request euthanasia, doesn’t this undermine the psychiatrist who is trying to keep hope alive:

The possibility of a physician-assisted death adds a problematic new aspect to psychiatric treatment. For patients, it can become a seemingly perfect solution that precludes difficult therapeutic work to resolve problems in their lives and in themselves. For psychiatrists, it can be seen as the ultimate patient demand that carries the weight of transference and countertransference with an unprecedented seriousness. The possibility that the patient at any time is free to seek assistance with death from another physician may induce a frustrating therapeutic atmosphere.

Whether or not depressed patients are suffering from moral distress, Denys suggests that psychiatrists are:

Moral distress is the state experienced when moral choices and actions “of doing the right thing” are constrained by conflicts of interests or public expectations. It arises for psychiatrists in their efforts to fulfill two conflicting roles; they are held accountable simultaneously for the healing of mental suffering and the preservation of life.
For my part I am not clear about why healing suffering and preserving life are in conflict.

Anyway, over the past two decades Dutch psychiatrists have increasingly rejected euthanasia as a treatment for depression:

Paradoxically, although the number of requests has increased in the Netherlands, psychiatrists have become more reluctant toward euthanasia. In 1995, 53% of psychiatrists found it inconceivable to ever consider euthanasia; in 2015, 63% of psychiatrists rejected euthanasia

How did we get to this point? The reasons are cultural. They derive from cultural attitudes and beliefs. First, is what Denys correctly calls a “supreme right of self-determination:”

First, Western societies are increasingly dominated by a drive toward more autonomy for the individual and the supreme right of self-determination. Being in control has become the ultimate moral virtue of Western citizens. We desire full control not only of our life but of our death as well. People believe it is necessary to regulate birth and now death.

We do not define ourselves in terms of our relationships with other people or in terms of our duties to them. We see ourselves as self-involved, self-absorbed human monads.

To that I would add that some people believe that by committing suicide they are doing the world a favor. See the notion of altruistic suicide, articulated by Emile Durkheim in his book, aptly named: Suicide:

And then, Denys concludes, psychiatry has expanded its own scope… to care about quality of life. It no longer limits itself to symptom reduction but it wants to improve the life of people who are mentally distressed. This corresponds roughly to the prescription of exercise as a preventative measure, against both physical and mental illness.

One might ask whether said patients might also be morally distressed, and whether psychiatrists are the best trained to offer such counsel:

Second, in past decades, psychiatry has gradually shifted its goals from treating symptoms of “patients” with diseases to augmenting quality of life of “clients”who are mentally stressed.With an emphasis on quality of life instead of treatment, reduction of suffering has become a priority and a responsibility of psychiatry. Psychiatry now maintains a balance between the border of treating disorders and providing patients a happy life. Finally, the possibility of euthanasia may lower many people’s threshold for ending their lives. The legalization of euthanasia not only appears to justify morally the intention to die, it also institutes suppliers of the services who encourage the demand for euthanasia.

When a nation approves of euthanasia as a potential treatment for depression, it makes treatment that much more difficult. 

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