Friday, November 13, 2015

If You Don't Get Better, We Can Always Kill You

My co-blogger, ClinkShrink, has very strong opinions on Physician Assisted Suicide.  My personal opinions are less strong, though with 40,000 suicides in the US every year, I'm not sure why it's necessary to involve physicians as the agents of death; we went into this field to help people, not to kill them.  But I don't believe that every suicide is necessarily either the result of mental illness or a tragedy.  We all die, and for myself, if all that remains of my life is suffering, I'd like to go quickly.  Clink and I say that she's worried they'll knock her off too soon and I'm worried they'll keep me around too long. 

But what about psychic suffering, which by anyone's measure, is just as bad, if not worse than physical pain.  I've had a patient tell me that his cancer treatments with all their complications, didn't compare to the pain of his depression.  And certainly, many people do decide that their psychic pain is unbearable, or believe they've become a burden to others, and so end their own lives.  But should doctors have a role in this?  Should we kill people because they have treatment-refractory depression?  I'm thinking that's not a good idea and please don't show up at my office looking for your lethal prescription.

In Belgium, psychic torment is an acceptable reason for euthanasia. And they even have a menu: you can drink a potion, or a doctor will administer a lethal injection.  That's right, in the land of beer and chocolate, the doctor will actually murder you in the name of medicine. 

 The YouTube above is haunting.   Emily has struggled with depression for a dozen years, and she's been approved for euthanasia.  I'm going to tell you that Emily changes her mind at the end because if you don't know that this lovely 24 year old young woman lives, it's unbearable to watch. I find it hard to imagine that there is ever nothing that can be done to alleviate at least some of the pain ...even if it's ECT or ketamine, or TMS, or a few cocktails to temporarily numb the pain (~if you try that one, please don't drive afterwards) and no hope of a new treatment that might make it better.  In this case, the events of the two weeks prior to her death date -- time spent meeting with friends to connect and say goodbye, getting ready -- were a period where the pain eased up.  Emily felt better knowing there was a way out, she found hope in the prospect of death.   


PseudoKristen said...

When the 3 physicians agreed she could commit suicide they were in effect saying that she was right there was no hope. But, there was hope as evidenced by the fact that she changed her mind. I think it's terrible that any physician would help a depressed patient die. Their job should be to help her find a way to live.

Steven Reidbord MD said...

California just passed a physician aid in dying law, although it is not likely to take effect in the next year or two. Like the laws another states, it only applies to those with a terminal disease, and must be self-administered: "ingested", no injections. In contrast, Belgium and the Netherlands permit active euthanasia ("mercy killing"), including for unremitting psychological distress. This New Yorker piece discusses some of the dilemmas in Belgium:

I agree with P-K that it's sadly misguided for doctors to aid in a depressed person's suicide. The reason is that enlisting others changes the nature of suicide from a solitary act to a community rite. It implicitly offers permission: "these 3 doctors studied my case and agree there's no hope." It can relieve the patient's guilt about proceeding, and normalizes the choice to die. Going a layer deeper dynamically, it facilitates the projection of anger onto the doctors, relieving the patient of anxiety and self-hatred, while confirming the patient was a bad child to begin with, deserving of destruction. In Emily's case, her self-cutting can be replaced by the deadly needles of parental authority figures, the fulfillment of her death-wish fantasy.

Emily could commit suicide just as easily and peacefully by herself. Euthanasia for a young person like her serves merely to legitimize her plan. Aid-in-dying in places like Oregon is a very different matter, where suitable patients are mostly elderly, already dying, and seeking control over their last days.

bluejonah said...

How come my comment wasn't approved?! I realize I have a different opinion, but I don't think that should be a reason to censor it.

Dinah said...

BlueJonah -- your comment was a direct attack on ClinkShrink and hostile in it's tone. If you'd like to send a dissenting opinion that's fine.

moviedoc said...

Every competent adult has a right to decide when and whether to die. Hands off to the state, which is supposed to be separate from church. It's the decision of the individual, not some other party who thinks some sort of so-called "hope" that exists in their minds gives them the authority to impose their values on that individual. As we know people can kill themselves without assistance. Pretending to control this human behavior works no better than drug/alcohol prohibition. We need less government intrusion in private matters.

Robin Williams might be alive today if he had not had to fear being labeled as crazy and locked up for talking about a wish to die. At least maybe he would not have died alone.

moviedoc said...

I will add that if Clink wants to get us docs out of this loop I'm all for it. Make all drugs except antibiotics over-the-counter. That way people who want to kill themselves will have the option of purchasing their life ending drug of choice without involving a physician. It might also make for fewer impulsive suicides. A lot of terminal patients here in Washington choose not to use barbiturates purchased for the purpose. And while we're at it, get all medical professionals out of the role of suicide cop. That will leave us better able to diagnose and treat mental disorders, which is what we're supposed to do.

TruePath said...

How about instead of actually performing physician assisted suicide we actually treat patients with severe psychic issues AS IF failing to find an effective treatment was a worse outcome than death.

We have plenty of drugs which certainly enhance mood in the short term and even long term (there are studies on the use of both amphetamines and opiates as anti-depressants and I know from personal experience that long term amphetamine prescriptions can sometimes work for depression). I'm not claiming these are generally effective or that medically authorized opiate abuse wouldn't often end in overdose but we should certainly give it a try...if all that gets accomplished is patients enjoy the ride for awhile before they die it's still a win.

So yes, we should have a process by which patients can get approval for physician assisted suicide for depression. They should get that approval just so everyone in the process will regard treatment resistant psychic illness the same way they would brain an imminent threat requiring desperate measures.

It need not literally authorize physician assisted suicide but we need some legal document declaring that someone's psychic suffering is persistent and extreme enough that we respect their choice to try high risk treatments (and therefore legally immunize their doctor).

Maybe someone (some possibly new professional organization) should just start issuing such authorizations. Even without legal authority it would do a lot to overcome the selfish attitude that as long as a depressed person is alive and physically well things are pretty much ok.

Cuvtixo said...

It's hard to believe you don't have strong feelings when you call euthanasia, "murder" even jokingly. I've recently heard of "suicide vacations" to Tiajuana and northern Mexico, where gringos buy Nembutal from vets. An "assisted suicide supporter" would tell his terminal patients to take it with their favorite alcoholic drink, and no one ever finished the drink. Also, there are 25 attempts for every "success". The most successful method is 12 guage shotgun to the head- which leaves a mess that no one should have to see, let alone clean up (even as a pro). I'm not going to weigh in when it might be or not be appropriate, but absolutely doctors are needed for legalized cases, like for the terminally ill, because the chances for success without expertise are much against them. The survival instinct is a real thing, but it's no more of a valid argument against suicide than sexual instinct is for promiscuous sex or sex for pay. If doctors avoid all involvement, we're going to continue to get a lot of repeat suicides and botched suicides from severely disabled people, not to mention illegal drug seeking and even drug dealing from people who are legitimately motivated by compassion. I feel it hard to understand why doctors might be highly motivated to act by the specter of young women using coat-wire hangers to abort their fetus, but think the equivalent actions by the terminally ill isn't their business.