End of life decision-making, euthanasia, and physician assisted suicide in persons with neuropsychiatric conditions

Clinical Center

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Abstract

In the past year, we have conducted the following projects. 1. Treatment resistant depression (TRD), psychiatric EAS, and the criterion of irremediability. One of the key criteria for psychiatric euthanasia in countries that allow it is irremediability and medical futility of the condition and the suffering arising from it. However, the current practice (as reflected in published reports that our group has studied extensively) relies on clinician judgments which may or may not reflect practices based on current evidence base. This project uses TRD as the paradigm condition and will provide a rigorous evidence-based review and analysis to answer the question: How reliable and valid is a clinician's judgment in making a prediction about a patients future clinical status and course? In so far as jurisdictional rules require consideration of evidence for answering such questions, a systematic review of relevant data will be crucial. 2. Switzerland is one of the countries that allow physician-assisted deaths. In collaboration with Professor Rafael Cohen-Almagor from University of Hull, we continue our study of the Swiss practice through the eyes of the organizational and medical experts in that country. In the past year, we focused on the relationship between lay and medical models of assisted death, as seen through the eyes of assisted suicide experts in Switzerland. We found that although the official model in Switzerland is a lay organization managed model, there is inevitable involvement of doctors due to preferred methods of dying and due to most requestors being medically ill. However, there are a variety of perspectives regarding the pros and cons of medical involvement, which we document and analyze. 3. Physician-assisted death (PAD) for people with nonterminal illnesses (PAD-NT) is a controversial practice legal in some countries and increasingly debated in others, including the United States. A major concern is that a lack of resources may drive some with mental illnesses or physical disabilities to seek PAD. We assessed US public opinion on PAD-NT under conditions of resource limitation. We found that a minority of the US public supports PAD-NT in the context of inadequate resources, with much lower support for PAD-NT for mental illness than for physical disability, suggesting that PAD-NT policy debates and future research should address the issue of whether sufficient resources must be available to potential requestors of PAD-NT. 4. Some PAD jurisdictions require intolerable suffering as a criterion for eligibility, usually requiring that it be based on a medical condition that cannot be remediated. In those jurisdictions, such as the Netherlands, some people (e.g., the Heringa case in the Netherlands) have challenged the medical suffering requirement in court, although ultimately losing the case. I wrote an analysis of the implications of using suffering as a criterion for PAD, as it can be argued that: on the one hand, it discriminates against persons who suffer from sources other than specified by law (e.g., poverty, misfortune in life) and on the other, it discriminates against those with medically qualified suffering but who do not wish to pursue PAD on those grounds as the permissibility on those grounds creates a stigmatized existence for such persons. 5. With the advent of rapidly acting treatments for depression, there is a need to revisit the often talked about situation of a depressed, terminally ill person seeking PADin regard to whether it is depression driving the request, whether the person is competent, etc. We performed an ethical analysis of this question, reviewing the emerging rapid response treatments for depression in the context of various PAD laws.